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MINUTES - 11081994 - 2.1
T0: BOARD OF SUPERVISORS Contra FROM: Ad-Hoc Committee on Consultant Selection "F i` Costa (Supervisor Tom Torlakson and Supervisor Mark DeSaulni := County a 40 Phil Batchelor, County Administrator DATE: arra i`dui+ki c November 2, 1994 SUBJECT: Status Report on "Second Opinion" on Merrithew Hospital Replacement Project Financing Defeasance SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: ACKNOWLEDGE receipt of Status Report on "Second Opinion" on Merrithew Hospital Replacement Project Financing Defeasance. BACKGROUND: The Ad-Hoc Committee appointed by the Board selected legal and financial consultants to provide a second opinion on the legal and financial ramifications of a defeasance of the 199,2 Certificates of Participation issued to finance the Merrithew Memorial Hospital Replacement Project. The selected consultants, the law firm of O'Melveny & Myers and the CS First Boston Corporation, have completed their review and opinions. A summary of the findings is enclosed followed by the background documentation. The background includes the prior opinions and financial analysis from the bond counsel and financial advisor for the County as well as a summary of project expenses. At the request of a member of the Board, enclosed for your information are copies of two past consultant reports and one Board report which helped form the basis for the Board's decision`to replace the Merrithew Hospital. In addition, a copy of the Official Statement, the disclosure document used by the original underwriter for the sale of the 1992 Certificates of Participation for the Hospital financing is included for your information. We are including source documents rather than executive summaries so that you may have more detailed background information available for your review. CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE (S): ACTION OF BOARD ON November 82 1994 APPROVED AS RECOMMENDED X OTHER X APPROVED the recommendation as presented, and REQUESTED staff to report further in December 19'94 . VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE XX UNANIMOUS(ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. ATTESTED November 8 , 1994 Contact: Health Services Director PHIL BATCHELOR.CLERK OF THE BOARD OF cc: County Counsel SUPERVISORS AND COUNTY ADMINISTRATOR County Administrator BY DEPUTY i� l ......:, .•....,_ ......... . ......: Tp:v, ,' _ .. :.h{tiR::4..isC%tY;tiYi:C]>H`]. :}h:<ti}i:�,i?i:.^..:7t?•X' ............_...._.. . . .. ... .. October 17, 1994 Comparison of Defeasance issues: i'. Issues Orrick Q'Melveny 1. Can the County change the location of the project? no no 2. Can the project be sublet? maybe(1) yes I� 3. Can the obligation be assummed 11 by another public agency and release the County from the;iliability? no no 4. Same as#3 but retain liability? yes yes 5. Does the County have an obligation to complete the project? yes yes 6. Can the Facility Lease be split into separate leases of parts of the project? no no 7. Can a defeasance work if the Capital Appreciation Certificates remain outstanding? yes yes 8. Can the County abandon the project and continue to make payments? no no 9. Can the Facility Lease be amended to to change the location of the Project? no no 10. What is the best way to defease the COP's? N/A(2) Fund with Asset Transfer(3) Prager,McCarthy & Sealy_ CS First Boston 11. What is the cost of defeasance? $22,912,832 (4) $24,933,857 (5) 12. What is the best way to defease the COP's? Fund escrow to maturity The bond counsels have both agreed that it is possible to defease the certificate of participation issue II for Merrithew. The process to defease the issue requires that sufficient U.S.Government securities be placed into an escrow so that the principal and interest are sufficient and timed to match the debt service and maturities of the certificates to be defeased. Funds to pay for the escrow would come from the remaning certificate proceeds held by the Trustee and any other funds available to the County. The yield on the securities purchased with unspent proceeds of the original issue and the County's own funds will be restricted to the arbitrage yield on the original issue. The yeild on securities purchased with�lproceeds of an asset transfer issue will be restricted to the arbitrage yield on the asset transfer issue. All of the escrow would be required to be purchased at the time of defeasance so that the entire issue was defeased. A detailed schedule of the actual and estimated expenses through December 31, 1994 for the project is attached. (1) The project can',be subleased subject to significant federal tax constraints relating mainly to- the nature of the, sublessee. Formal approval by the IRS may be required. (2) Orrick was not sked to consider this question (3) Asset transfer for purposes of funding escrow may require a 4/5 vote of the Board of Supervisors or"other requirements depending upon the type of financing usedand proceeds would be yield restricted to asset transfer certificate arbitrage yield (4) Prager's estimate of May 12, 1994 based upon a June 1, 1994 defeasance (5) First Boston's estimate based upon January 1, 1995 defeasance w.rtvC:'G4J:'{+Y.1^ -e:.'i!.7ti}{24�C3sti:v_.>fii.-�:is}i.S..!'::�•:'i"._...,..y...;::. .4:' .... .. _ October 7, 1994 Merrithew Memorial Hospital Replacement Project I. Project costs through 8/31/94: Architect and other consultants $ 6,514,875 State plan check fees 808,520 Insurance 447,612 Construction and demo contracts 1,359,088 Equipment 874,399 Other costs 1,069,646 Total $11,074,140 11. Other costs: Capitalized interest $15,290,880 .Cost of issuance 372,157 Trust administration 3,460 Underwriters discount 1,076,004 Total $16,742,501 I11. Total expenses through 8/31/94 $27,816,641 IV. Estimated costs from 8/31/94 to 1/1/95: Construction and,administration 11 September estimate(known) $ 192,188 Oct,Nov;Dec. estimate 600,000 Capitalized interest due Oct. 15. - 3,887,551 Cap. interest accrued 10/15-12/31/94 1,619,912 Total $ 6,299,551 V. Total proj. and fin. costs,actual and estimated to 1/1/95 $34,116,192 Defeasance of the issue would require cancellation of numerous construction and consulting contracts. The liquidated damages resulting from the cancellation is unknown,but is estimated to require $2,000,000. CS FIRST BOSTON CS First Boston Corporation 101 California Street Suite 4300 San Francisco,CA 94111-5802 Telephone 415 765 7000 CONTRA' COSTA COUNTY RECEIVED October 14, 1994 � 1 DeRoyce Bell t OCT 17 1994 Deputy County Adm' Iuiistrator Contra Costa County 651 Pine Street, 11th Floor OFFICE OF Martinez,CA 94553-1229 COUNTY ADMINISTRATOR Dear Mr.Bell: Please find attached a financial analysis of the cost of defeasance for the Merrithew Memorial Hospital Replacement Project Certificates of Participation. This is in response to your authorization to execute this analysis dated October 5, 1994. Attached is a Summary Table of our analysis accompanied by integral footnotes that provide sources, methodology and assumptions. Praeger,McCarthy&Sealy,the County's Financial Advisor and O'Melveny&Meyers,;the special counsel retained by the County,were contacted and provided supplemental infolmahon. Additionally,Joe Forrester,a Director at CS Fust Boston and former tax counsel at Dewey Ballentine,was consulted regarding the permitted investment strategy for the defeasance escrow. Current fund balances and investments as provided by the Trustee,U.S.Trust, were also used in the analysis. Please note that this analysis is not a recommendation to execute a defeasance on the Series 1992 Certificates of Participation,nor an opinion that such a defeasance would be legal. We suggest that the County contact both the County's Financial Advisor and Bond Counsel for specific further information. Should you have any questions or require additional information,please do not hesitate to contact either myself fat(415)765-7035 or Sharon Gillespie at(415)765-7042. Sincerely, John Henry Pollock Vice President cc: Arnold Mazzotti,Praeger,McCarthy&Sealy Gil Ray,O'Melveney&Meyers I' :: jCASHFLOW TO FUND DEFEASANCE OF 1992 MERRITHEW HOSPITAL BONDS Reference LIABILITIES Notes Cost of Escrow $126,354,080 (1) Miscellaneous Defeasance Fees (Legal,Trustee,etc.) 175,000 (2) Capitalized Interest Payment November 1,1994 3,887,512 Liquidated Damages for,Contract Cancellations 2,000,000 (2) Project Costs through 12/31/94 1,541,238 (3) Total Liabilities $133,957,830 i ASSETS Fund Balances (4) Construction Fund $ 70,070,455 Lease Fund 26,645,043 Reserve Fund 11,358,479 Trust AdministrationFund 1,540 - Estimated Income on Fund Balances through 12/31/94, 948,456 (5) Total Assets $109,023,973 FUNDING SHORTFALL $24,933,857 Notes: (1) Although an economic defeasance could produce a lower escrow cost by expanding the universe of permitted investments,it would Limit the County in terms of debt capacity and other covenants required under the Indenture. Thus,the analysis considered a legal defeasance of the Bonds based on three scenarios,with the least- cost scenario used in determining funding shortfall: Scenario Cost of Escrow • Creating„an escrow without calling the $126,354,080 .bonds i • Creating!lan escrow with the first $126,770,638 available call option on November 1, 2002,X1102% - • Creatingian escrow with a par call on $126,783,268 November 1,2004 Permitted investments for a legal defeasance escrow are U.S.Government securities;and our analysis assumes purchasing SLGS to achieve the maximum allowable yield/lowest escrow cost. The escrow for a legal defeasance will be restricted to the arbitrage yield of the 1992 Bonds(6.7351389%). Escrow requirements for each scenario are attached. (2) Estimates provided by the County of Contra Costa. (3) Project costs through 12/31/94 include those estimated by the County as well as an outstanding requisition of $749,050 (4) Balances of all bond funds related to the 1992 Bonds will be available to purchase securities to fund a defeasance escrow. Fund balances indicated are based on those provided by Trustee as of October 7,1994,and are currently invested in the California,Arbitrage Management Program(CAMP)Money Market Pool. (5) Estimated income on fud balances is based on available funds to be invested between October 14 and December 31 at an interest rate of 4.40%(annualized current yield of CAMP Money Market Pool). GASHARED\DEAL\CCCOMISMHOSPDEES.DOC 10/14194 d COUNTY OF CONTRA COSTA MERMTHEW MEMORIAL HOSPITAL REPLACEMENT PROJECT CERTIFICATES OF PARTICIPATION,SERIES 1992 Escrow Requirements to Maturity Premium: 0.00% Debt Service on Bonds Date_ Principal Coupon Interest Escrow Requirement 5/1/95 3,887,511.88 3,887,511.88 111/1/95 3,887,511.88 3,887,511.88 5/1/96 3,887,511.88 3,887,511.88 11/1/96 3,887,511.88 3,887,511.88 511/97 3,887,511.88 3,887,511.88 11/1/97 3,887,511.88 3,887,511.88 5/1/98 3,887,511.88 3,887,511.88 1111/98 2,885,000.00 5.700 3,887,511.88 6,772,511.88 5/1/99 3,805,289.38 3,805289.38 1 V1/99 3,045,000.00 5.800 3,805289.38 6,850289.38 5/1/00 3,716,984.38 3,716,984.38 1 V1/00 3225,000.00 6.000 3,716,984.38 6,941,984.38 5/1/01 3,620,234.38 3,620234.38 - 11/l/01 3,415,000.00 6200 3,620234.38 7,035234.38 5/1/02 3,514,369.38 3,514,369.38 11/1/02 3,630,000.00 6.250 3,514,369.38 7,144,369.38 5/1/03 3,400,931.88 3,400,931.88 11/1/03 3,855,000.00 6.300 3,400,931.88 7255,931.88 5/1/04 3279,499.38 3,279,499.38 1111/04 4,100,000.00 6.400 3,279,499.38 7,379,499.38. 5/1/05 3,148,299.38 3,148299.38 11/1/05 4,360,000.00 6.400 3,148,299.38 7,508299.38 5/1/06 3,008,779.38 3,008,779.38 11/1/06 4,640,000.00 6.500 3,008,779.38 7,648,779.38 5/1/07 2,857,979.38 2,857,979.38 11/1/07 1,731,788.45 0.000 6,071,190.93 7,802,979.38 5/1/08 2,857,979.38 2,857,979.38 11/1/08 4,940,000.00 6.600 2,857,979.38 7,797,979.38 5/1%09 2,694,959.38 2,694,959.38 11/1/09 5270,000.00 6.600 2,694,959.38 7,964,959.38 5/1/10 2,521,049.38 2,521,049.38 11/1/10 5,615,000.00 6.600 2,521,049.38 8,136,049.38 5/1/11 2,335,754.38 2,335,754.38 11/1/11 5,985,000.00 6.600 2,335,754.38 8,320,754.38 5/1/12 2,138249.38 2,138249.38 11/1/12 6,380,000.00 6.600 2,138249.38 8,518249.38 5/1/13 1,927,709.38 1,927,709.38 11/1/13 1,537,725.85 0.000 7,194,983.53 8,732,709.38 5/1/14 1,927,709.38 1,927,709.38 11/1/14 1,434,76620 0.000 7297,943.18 8,732,709.38. 5/1/15 1,927,709.38 1,927,709.38 11/1/15 1,339,731.30 0.000 7,397,978.08 8,737,709.38 5/1/16 1,927,709.38 1,927,709.38 11/1/16 6,800,000.00 6.625 1,927,709.38 8,727,709.38 5/1/17 1,702,459.38 1,702,459.38 11/1/17 7255,000.00 6.625 1,702,459.38 8,957,459.38 5/1118 1,462,137.50 1,462,13750 11/1/18 7,735,000.00 6.625 1,462,13750 9,197,13750 5/1/19 1205,915.63 1205,915.63 11/1/19 8245,000.00 6.625 1205,915.63 9,450,915.63 5/1120 932,800.00 932,800.00 11/1/20 8,790,000.00 6.625 932,800.00 9,722,800.00 5/1/21 641,63125 641,63125 11/1121 9,375,000.00 6.625 641,63125 10.016,63125 5/1/22 331,084.38 331,084.38 11/1!22 9,995,000.00 6.625 331,084.38 10,326,084.38 125,584,011.80 164,195,531.95 289,779,543.75 COUNTY]OF CONTRA COSTA MERRITHEW MEMORIAL HOSPITAL REPLACEMENT PROJECT CERTIFICATES OF PARTICIPATION,SERIES 1992 Escrow Requirements to First Call: 11/1/02 Premium: 2.00% i Debt Service on Bonds Date Prindpal Coupon Interest Escrow Requirement 5/1/95 3,887,511.88 3,887,511.88 11/1/95 3,887,511.88 3,887,511.88 5/1/96 3,887,511.88 3,887,511.88 11/1/96 3,887,511.88 3,887,511.88 5/1/97 3,887,511.88 3,887,511.88 11/1/97 3,887,511.88 3,887,511.68 5/1/98 3,887,511.88 3,887,51188 11/1/'98 2,885,000.00 5.700 3,887.511.88 6,772,511.88 5/1/99 3,805289.38 3,805,289.38 11/1/99 3,045,000.00 5.800 3.805289.38 6,850289.38 5/1/00 3,716,984.38 3,716,984.38 11/1/00 3225,000.00 6.000 3,716,984.38 6,941,984.38 5/1/01 3,620234.38 3,620234.38 11/1/01 3,415,000.00 6.200 3,620234.38 7,035,234.38 5/1/02 3,514,369.38 3,514,369.38 11/1/02 3,630,000.00 6.250 3,514,369.38 112,551,169.38 5/1/03 3,400,931.88 11/1/03 3,855,000.00 6.300 3,400,931.88 5/1/04 3,279,499.38 11/1/04 4,100,000.00 6.400 3,279,499.38 5/1/05 3,148,299.38 11/1/05 4,360,000.00 6.400 3,148299.38 5/1/06 3,008,779.38 11/1/06 4,640,000.00 6.500 3.008,779.38 5/1/07 2,857,979.38 11/1/07 1,731,788.45 0.000 6,071,190.93 4,945,000.00 5/1/08 2,857,979.38 11/1/08 4,940,000.00 6.600 2,857,979.38 5/1/09 2,694,959.38 11/1/09 5,270,000.00 6.600 2,694,959.38 5/1/10 2,521,049.38 11/1/10 5,615,000.00 6.600 2,521,049.38 5/1/11 2.335,754.38 1 VIA 1 5,985,000.00 6.600 2,335,754.38 5/1/12 2,138249.38 11/1/12 6,380,000.00 6.600 2,138249.38 5/1/13. 1,927,709.38 11/1/13 1,537,725.85 0.000 7,194,983.53 6,805,000.00 5/1/14 1,927,709.38 _ 11/1/14 1,434,76620 0.000 7297,943.18 .6,805,000.00 5/1/15 1,927,709.38 11/1/15 1,339,731.30 0.000 7,397,978.08 6,810,000.00 5/1/16 1,927,709.38 11/1/16 6,800,000.00 6.625 1,927,709.38 5/1/17 1,702,459.38 11/1/17 7255,000.00 6.625 1,702,459.38 5/1/18 1,462,13750 11/1/18 7,735,000.00 6.625 1,462,13750 5/1/19 1205,915.63 11/1/19 8245,000.00 6.625 1205,915.63 5/1/20 932,800.00 11/1/20 8,790,000.00 6.625 932,800.00 5/1/21 641,63125 11/1/21 9,375,000.00 6.625 .641,63125 5/1/22 331,084.38 11/1/22 9,995,000.00 6.625 331,084.38 125,584,011.80 164,195,531.95 207,385,650.00 ..:.iSiSXiSYfXK><Xn>fYQQ<fi?S1iH}LY•i" ... ...:..:._ ..,.,. _ .... ...... ... ...... .. ... , M1 COUNTY OF;CONTRA COSTA MERRITHEW MEMORIAL HOSPITAL REPLACEMENT PROJECT CERTIFICATES OF PARTICIPATION,SERIES 1992 Escrow Requirements to Par Call: 11/1/04 Premium: 0.00% Debt Service on Bonds Date Principal Coupon Interest Escrow Requirement 5/1/95 3,887,511.88 3,887,511.88 11/1/95 3,887,511.88 3,887,511.88 SM/% 3,887,511.88 3,887,511.88 11/1/96 3,887,511.88 3,887,511.88 !6/1/97 3,887,511.88 3,887,511.88 11/1/97 3,887,511.88 3,887,511.88 5/1/98 3,887,511.88 3,887,511.88 11/1/98 2,885,000.00 5.700 3,887,511.88 6,772,511.88 5/1/99 3,805289.38 3,805289.38 11/1/99 3,045,000.00 6.800 3,805289.38 6,850289.38 16/1/00 3,716,984.38 3,716,984.38 11/1/00 3225,000.00 6.000 3,716,984.38 6,941,984.38 15/1/01 3,620,234.38 3,620234.38 11/1/01 3,415,000.00 6200 3,620,234.38 7,035,234.38 5/1/02 3,514,369.38 3,514,369.38 11/1/02 3,630,000.00 6.250 3,514,369.38 7,144,369.38 5/1/03 3,400,931.88 3,400,931.88 11/1/03 3,855,000.00 6.300 3,400,931.88 7,255,931.88 5/1/04 3279,499.38 3,279,499.38 11/1/04 4,100,000.00 6.400 3,279,499.38 102,764,499.38 5/1/05 3,148299.38 11/1/05 4,360,000.00 6.400 3,148299.38 5/1/06 3,008,779.38 ill/l/06 4,640,006.00 6.500 3,008,779.38 5/1/07 2,857,979.38 11/1/07 1,731,788.45 0.000 6,071,190.93 4,945,000.00 5/1/08 2,857,979.38 11/1/08 4,940,000.00 6.600 2,857,979.38 5/1/09 2;694,959.38 11/1/09 5270,000.00 6.600 2,694,959.38 SM/10 2,521,049.38 11/1/10 5,615,000.00 6.600 2,521,049.38 5/1/11 2,335,754.38 11/1/11 5,985,000.00 6.600 2,335,754.38 5/1/12 2,138,249.38 111/1/12 6,380,000.00 6.600 2,138249.38 6/1/13 1,927,709.38 11/1/13 1,537,725.85- 0.000 7,194,983.53 6,805,000.00 5/1/14 1,927,709.38 - 11/1/14 1,434,76620 0.000 7297,943.18 6,805,000.00 5/1/15 1,927,709.38 11/1/15 1,339,731.30 0.000 7,397,978.08 6,810,000.00 5/1/16 1,927,709.38 11/1/16 6,800,000.00 6.625 1,927,709.38 6/1/17 1,702,459.38 11/1/17 7255,000.00 6.625 1,702,459.38 5/1/18 1,462,13750 11/1/18 7,735,000.00 6.625 1,462,13750 5/1/19 1205,915.63 11/1/19 8245,000.00 6.625 1,205,915.63 5/1/20 - 932,800.00 11/1/20 8,790,000.00 6.625 932,800.00 5/1/21 641,63125 11/1/21 9,375,000.00 6.625 641,63125 . 5/1/22 331,084.38 11/1/22 9,995,000.00 6.625 331,084.38 125,584,011.80 164,195,531.95 218,679,71250 • I� PRAGER, MCCARTHY &SEALY INvFSTmENr BANKERs May 12, 1994 Mr. Phil Batchelor' County Administrator and Clerk of the Board County of Contra ,Costa County Administration Building 651 Pine Street. lith Floor Martinez, CA 94553 RE: ESTIMATED COST TO ABANDON MERRmmw MEMORIAL HOSPITAL REPLACEMENT PROJECT Dear Phil, In response to your inquiry concerning the estimated cost of abandoning the Merrithew Hospital Replacement Project, we have prepared the enclosed numerical summary. This summary reflects 'the same assumptions and numerical analysis we recently utilized in preparing the response to the R Neal Gilbert declaration. As indicated in the summary, the County raised $122,709,766 in bond proceeds when it sold the $125,584;011.80 of Certificates of Participation (the "1992 COPS") to finance the hospital project iri May, 1992. According to the County's and the Trustee's records, approximately $25:,313,154.has been spent on the project and approximately $8,603,388 has been earned on fund balances _associated with the project-as of April 21, 1994. Consequently, approximately $106,000,000 of bond proceeds have not yet been spent on the project and would be.available to contribute toward the cost of abandoning the project. In determining th'e total cost of project abandonment, we estimated the cost of defeasing the 1992 COPs on June 1, 1994 to be $125,620,162. This figure is based upon market rates as of April 21, 1994 and assumes that the available $106,000,000 of remaining bond proceeds will be contributed to the escrow account and will be invested at yields no higher than the yield on the 1992 COPs (approximately 6.73%). . The source of the remaining $19,620,162 needed for the escrow fund is not identified, although we have assumed that the funds would not have to be yield restricted since they are not bond proceeds. In addition to the II'escrow defeasance costs, abandonment of the project would also entail i) legal, trustee, and advisory fees, ii) recovery of the underwriter's discount paid for the 1992 COPs, iii) potential rebate liability associated with investment income received on 1992 4 ' l County of Contra Costa Estimated Costs of Project Abandonment Merrithew Hospital Replacement Project Page 2 i COPS fund balances, and iv) costs associated with canceling project-related contracts. Utilizing the estimated costs for these items and assuming that the County earns an additional$883,332 on 1992 COPS fund balances through June 1, the net cost associated with abandoning the project is estimated to total$22,912,832. In addition to the.estimated direct costs contained in enclosed summary,we wish to point out that the Couriity may also suffer substantial indirect costs if it abandons the project. A major example of(such indirect costs would be the additional interest expense on future County marketable debt borrowings that would occur if the rating agencies downgrade the. County's credit status as a result of abandonment of the hospital project. We wish to emphasize that the enclosed summary is an estimate based upon information we obtained form the;County and from the Trustee. To the extent i) that more recent expense and investment records become available, ii) that market rates change, or iii) that the County defeases the 1992 CON on a date other than June 1, 1994, the estimated cost of project abandonm nt would need to be completely updated. Please do not hesitate to contact me if you have any questions. Sincerely, PRA.GER,MCCAR=&SEALY %,,,—A (--V4�_� Arnold F. Mazotti Vice President cc De Royce Bell,Deputy County Administrator �..,:.....:�.::.:.,..i.,_._+��:..���ocK<.�:�::ry?:M•wc�r.'c:._>?<Fadi4Sii•:Kw.;r.•:>•�.w�:�>:N .........: .... ... ... x k� : Mss�M�/�M '0 O LO mOCD O LA V l to O � N O 6'4 N eM d� O 0000 N O er O O \0 O m N tpN .-4 00 \00000 \O Omm r— �NO \O M .-BOO OOrw 0m00 00 u7 O� M O O%0 O O \0 O m N °fir-400 O NONOOk 000r-4 OOMm \0 (D a00C � N N 0 N 69 V 60 Lr v V :. in � b \0 •�..1 �Or \\0j c \04-1 6q 3 M w U c u L`7 V u 0 0 0 tn [� N � � � � � 4r, 00 \0 m O O\ O 0 c Q DD •� "� Ifl +` 3 r-1 H •� u y N o H Myo _ coa` Ou to Ln ti — ,,,,// u O opt uo u uw° �o \ ° uw H [ �• o. oon �o o i-1 n a N 0- 0 h " bA c fes° v c c/j y ON v �" u .0 .-4 �+ �, u c ij u b w t�7 N O'o O v, u u 'v �[ � CO c: -,o .--i o co U u " u v c. � � AcaV wW � m a � '� 41 u u U CilCd [ h 0 u U. .O c w p u < -d o u G u N O ~ ° 0 c A o u1. � .0 c c ,.;. ° rtJU � '� w N cry 0 n u u ° °. u c s ° u c EU ty E 0t— u r- Cl a c h N M M._x� dU � HSN O•MELVENY & MYERS 1999 AVENUE OF THE STARS 400 SOUTH HOPE STREET EMBARCADERO CENTER WEST 275 BATTERY STREET LOS ANGELES.CALIFORNIA 90067-6035 TELEPHONE 13101 S53-6700 LOS ANGELES. CALIFORNIA 90071-2899 SAN FRANCISCO.CALIFORNIA 94111-3301 FACSIMILE(310)246-6779 1 TELEPHONE(415) 984-6700 - TELEPHONE 12131 669-6000 - FACSIMILE 14(5) 984-8701 610 NEWPORT CENTER DRIVE - NEWPORT BEACH. CALIFORNIA 92660-6429 TELEX 674122FACSIMILE(2131 669-6407 10 FINSBURY SQUARE TELEPHONE 17141 760-9600 LONDON EC2A ILA FACSIMILE(714)669-6994 TELEPHONE(071) 256-8451 - FACSIMILE(0711 638-8205 555 131-STREET.N.W SANBANCHO KB-6 BUILDING TELEPHONE(22 0213383-5300 WASHINGTON, C 1109 October 6 SANBANCHO•CHIYODA-KU 8333 TOKYO 102 FACSIMILE(2021 383.5414 10th TELEPHONE(031 3239-2800 CITICORP CENTER 1 ^ ^`9 4 FACSIMILE(03)3239-2432 153 EAST 53-STREET j `J� NEW YORK. NEW YORK 10022-4611 TELEPHONE(2121 326-2000 FACSIMILE(212)326-2061 WRITERS DIRECT DIAL NUMBER OUR FILE NUMBER (213) 669-6453 173,892-002 642057.vl I Mr. De Royce Bell Deputy County Administrator County of Contra Costa County Administrator's Office 651 Pine Street, 11th Floor Martinez, CA 94553-0063 Re: iCounty of Contra Costa Certificates of Participation (Merrithew Memorial Hospital Replacement Project) Series of 1992 Dear Mr. Bell:' We have been asked to render an opinion to the County of Contra Costa (the "County") with respect to the $125,584,011.8'0 Certificates of Participation (Merrithew Memorial Hospital Replacement Project) Series of 1992 (the "Certificates",) , evidencing fractional undivided interest of the _ registered own!ers. thereof in base rental payments to be made by the County tolthe Contra Costa County Public Facilities Corporation (the "Corporation") . More specifically, we have been asked whether the County could (1) use available proceeds of the Certificates to finance the construction of facilities other than the Project as defined in the Facility Lease (Merrithew Memorial Hospital Replacement Project) by and between the County and the Corporation dated as of May 1, 1992 (the "Facility Lease") or (2) abandon the Project. In connection with rendering this opinion, we have reviewed the Site Lease (Merrithew Memorial Hospital Replacement Project) between the County and the Corporation dated as of May 1, 1992 (the ' Site Lease") , the Facility Lease, the Trust Agreement by and among U.S. Trust Company of California, NA, the i Page 2 - Bell, Mr. De Royce - October 10, 1994 i County and the Corporation dated as of May 1, 1992 relating to the Certif icatesl (the "Trust Agreement") , and the Official Statement relating to the Certificates dated April 29, 1992. In accordance with the Site Lease, the County leased to the corporation11certain real property (the "Demised Premises") situated in thejCounty for the purpose of financing the construction of the Project. In accordance with the Facility Lease, the Corporation leased to the County the Demised Premises and the Project to be constructed and located thereon. In accordance withlthe Trust Agreement, the Certificates were issued to provide funds to construct the Project. The term Project under the Facility Lease means Project Phase I and anySubsequent Phase of the Project. Project Phase I means those public facilities and buildings described in an exhibit attached to the Facility Lease to be constructed on the Demised Premises. The Facility Lease specifically provides that the parties agree that the proceeds of the Certificates will be used to financejthe acquisition, design, construction and financing of the Project. The County and the Corporation further agreed in the Facility Lease that Project Phase I will be substantially completed in accordance with the plans and specifications. ] The Facility Lease provides that the County shall only have' the right to remodel the Project or to make additions, modifications and improvements to the Project and the Demised Premises. The Facility Lease does not.provide for a substitution ofJ other property or other facilities. The Facility Lease also provides that in the event of default, the Corporation may, among other things, terminate the Facility Lease, re-enter and to relet the Demised Premises and the Project. The Trust Agreement provides, in relevant part, -that the use. of all 'moneys in the Acquisition and Construction Fund shall be held by the Trustee and applied to the payment of Project Cost. Project Cost means all costs of acquiring and constructing the Project. It further provides that the Site Lease and the Facility Lease can only be altered, amended or modified, for these purposes, if in the opinion of the Trustee (which opinion shall be based upon an opinion of counsel or a certificate of the County) that such. alterations, amendments or modifications are not materially adverse to the interest of the Certificate owners. Based on the foregoing, we are of the opinion that the County may not substitute other facilities for the Project. We base this opinion on the expressed language of the documents which (i) forecloses the opportunity to substitute property and (ii) provides the Trustee the right in the event of default to Page 3 - Bell, Mr. De Royce - October 10, 1994 relet the Project. We are of the view that it is a factual question whether the Certificate owners would be adversely impacted in thelevent of substitution of other facilities for the Project. We do not render opinions on factual questions. On the other hand, theji Trust Agreement provides that the Site Lease and Facility Lease may be amended if the Trustee concludes that the Certificate owners would not be adversely affected. The Trustee may be willing to rely on a certificate of the County in reaching its conclusion. ' The County has the right to abandon the Project. If it decides to abandon the Project the County would need to defease the Certificates. Because cost of issuance and a portion of the capitalized interest have been paid from proceeds of the Certificates, to defease the County would need to supplement the proceeds held by the Trustee with additional funds. We assume the goal would be to defease the Certificates until such time as the Certificate's could be prepaid. The Trust Agreement provides that the Certificates may be;prepaid on various dates commencing November 1, 2002 at an initial premium of 2% and declining to par in 2004. With respect to the most cost effective method to def ease the Certificates, we assume you will consult your financial advisors. The County may use as the source of funds for a defeasance any lawfully available funds on hand or it could refund the Certificates by issuing new certificates of participation. I The new certificates would need to be collaterized by some assets of the County that currently exist or that will come ,into existence when new facilities are developed. For example, the County could refund .the Certificates by issuing new certificates collaterized by the other facilities that the County would like to substitute for the Project. This opinion is being rendered to you solely for your benefit and may not be relied on by anyone else without our prior written consent. Respectfully Submitted, O'MELVENY MYERS 1999 AVENUE OF THE STARS 400 SOUTH HOPE STREET EMBARCADERO CENTER WEST L05 ANGELES. CALIFORNIA 90067-6035 27S BATTERY STREET TELEPHONE(310)553-6700 LOS ANGELES, CALIFORNIA 90071-2899 SAN FRANCISCO. CALIFORNIA 94111-3305 FACSIMILE 13101 246-6779 ' TELEPHONE(4151 984-8700 - TELEPHONE (213) 669-6000 FACSIMILE(4151 984-8701 610 NEWPORT CENTER DRIVE NEWPORT BEACH, CALIFORNIA 92660-6429 TELEX 674122 FACSIMILE(213) 669-6407 10 FINSBURY SOUARE TELEPHONE 1714)760-9600 LONDON EC2A ILA FACSIMILE(7141 669-6994 TELEPHONE(071)256-8451 FACSIMILE(071)638-8205 SSS 13T.STREET, N.W. WASHINGTON, D.C.200041109 - SANBANCHO KB-6 BUILDING TELEPHONE(202)383-5300 October 6 SANBANCHO,CHIYODA-KU FACSIMILE(202)383-541417yh TOKYO 102 11.. TELEPHONE(03)3239-2800 CITICORP CENTER 1.1 9 9 4 FACSIMILE(03)3239-2432 153 EAST S3^o STREET 7 ..�� .. NEW YORK, NEW YORK 10022-4611 r TELEPHONE(212)326-2000 C, FACSIMILE(212)326-2061 C^ppp .,A COUNTY RECEIVED WRITER'S DIRECT DIAL NUMBER OUR FILE NUMBER (213) 669-6453 1 OCT 2 1 1994 i OFFICE OF COUNTY ADMINISTRATOR 173,892-002 Mr. De Royce Bell Deputy County Administrator County of Contra Costa County Administrator's Office 651 Pine Street, lith Floor Martinez, CA 94553-0063 Re: County of Contra Costa Certificates of Participation (Merrithew Memorial Hospital Replacement Project) Series of 1992 Dear Mr. Bell: ( This, is a supplement to our opinion dated October 10, 1994 (the "Original Opinion") concerning the above referenced matter. All definitions used in the Original Opinion shall be applicable to this supplemental opinion. The purpose of this supplemental opinion is to respond succinctly to the nine questions set forth below. 1. Does the County have the option of changing the location of the project? Answer: No 2. Does the County have the right to sublet the project to another party? Answer: Yes 3 . Is it possible for the obligation represented by the existing transaction to be assumed by another governmental entity in a transaction which would release the County from liability? Answer: No 4 . Is it possible for the obligation represented by the existing transaction to be assumed by another governmental entity in a transaction which would not release the County from its liability? Answer: Yes :1:602iOGT'iu.J::v?:r'C�i4L:42LKKii'..i.:l.'wiu.-.K�L.. .....F t.c..._ •. .+. .. 1.x.4..... ..... . .r..... e.v..a.... ....... .. .. . _. ..,... Page 2 - Bell, De Royce - October 17, 1994 5. Does the County have an obligation to complete the project? Answer: Yes 6. Can the County voluntarily split the Facility Lease into ,separate leases or parts of the project? Answer: No 7. The Capital Appreciation Certificates are not subject to optional redemption? Can a defeasance work if the Capital Appreciation,. Certificates remain outstanding? Answer: Yes 8. Can County abandon the project and continue to make payments? Answer: No 9. Can the Facility Lease be amended to change locations of the Project? Answer: No All of the answers in the affirmative are subject to certain limitations and depend on the circumstances relating to the particular action. This supplemental opinion is subject to the same limitations set forth in the Original Opinion. Respectfully Submitted, GTR: lrg 643088[LA1] RRICK, HERRINGTON & SUTCLIFFE May 19, 1994 Direct Dial (415) 773-5524 DeRoyce Bell Deputy County Administrator County of Contr11 a Costa County Administrator's office 651 Pine Street, 11th Floor Martinez, CA 94553 Re: (County of Contra Costa Certificates of Participation i (Merrithew Memorial Hospital Replacement Project) Series of 1992 Dear DeRoyce: This letter is in response to certain questions regarding potential consequences that should be considered by the County before the County makes any changes to the County's plan for the acquisition and construction of the replacement project for the Merrithew Memorial Hospital (the "Project") . The Project is being financed from the proceeds of the Certificates of Participation discussed below. The County has requested us to answer certain questions concerning flexibility it has with regard to abandoning or substantially changing the Project. Background County of Contra Costa Certificates of Participation (Merrithew Memorial Hospital Replacement Project) , Series of 1992 (the "Certificates") , in the aggregate principal amount of $125,584,011.80, were delivered to investors on May 13, 1992. The Certificates were executed and delivered pursuant to a Trust Agreement,. dated as of May 1, 1992 (the "Trust Agreement") , by and among the County of Contra Costa (the "County") , the Contra Costa County Public Facilities Corporation (the "Corporation") and U.S. Trust Company of California, N.A. , as trustee (the "Trustee") and evidence fractional undivided interests in base rental payments to be made by the County pursuant to a Facility Lease, dated as of May 1, 1992 (the "Facility Lease") , between the County, as lessee, and the Corporation, as lessor. Old Federal Reserve Bank Building • 400 Sansome Street • San Francisco,California 94111-3143 Telephone 415 392 1122 • Facsimile 415 773 5759 S1r2-31085.1 Los Angeles 213 629 2020 • New York 212 326 8800 • Sacramento 916 447 9200 • Washington,D.C. 202 626 8660 QRRICK, HERRINGTON & SUTCLIFFE DeRoyce Bell May 19, 1994 Page 2 The Certificates were sold to finance the design and construction of I the Project, which is leased to the County pursuant to the'! Facility Lease. Prior to the completion of the Project, the Certificates are payable from a prefunded rental account held bylthe Trustee, and following completion and occupancy of the Project -by the County, the Certificates are payable from the base rental payments paid by the County pursuant to the Facility11Lease. Completion of the Project on time is essential to the security of the Certificates. It is our understanding that the County is presently proceeding with the Project. Additions to the Project are permitted to be financed from the proceeds of additional Certificates of Participation issued on a parlity with the outstanding Certificates upon satisfaction of, the conditions contained in the Trust Agreement. However, additions to the Project not located in the City of Martinez, California are subject to the condition that the acquisition and construction cost of the additions to the Project do not exceed $20,000,000. Additions to the Project located outside the City of Martinez in excess of this $20,000,000 limit cannot be financed pursuant to the Trust' Agreement on a parity with the outstanding Certificates. QUESTIONS The following questions have been asked with regard to this matter. As many factors go into the answers to these questions, we have not attempted to document our reasoning, but would be pleased to discuss these answers with you in greater detail if to do so would be helpful. 1. Does the County have the option of changing the location of the Project? No. 2. iDoes the County have the right to sublet the Project to another party? Possibly, depending on the circumstances, I with consent of Corporation and if no adverse tax or credit consequences would result. 3. ' Is it possible for the obligation represented by the existing transaction to be assumed by another governmental entity in a transaction which would release the County from liability? No". SF2-31085.1 QRRICK,HERRINGTON & SUTCLIFFE DeRoyce Bell May 19, 1994 Page 3 4. is it possible for the obligation represented by the existing transaction to be assumed by another governmental entity in a transaction which would not release the County from liability? Yes, depending on circumstances. 5. Does the County have an obligation to complete the Project? Yes. 6. Can the County voluntarily split the Facility Lease into separate leases of parts of the Project? No. 7. The Capital Appreciation Certificates are not subject to optional redemption. Can a defeasance work if the Capital Appreciation Certificates remain outstanding? Yes. 8. Can County abandon the Project and continue to make payments? No. 9. Can the Facility Lease be amended to change location of the' Project? No. Leqal Considerations The County has incurred a number of legal obligations to the purchasers of the Certificates. The Trust Agreement and Facility Lease contain promises of the County which require the County to complete the design and construction of the. Project in a timely manner: Any substantial change to the Project, or abandonment of the Project, would put the County in breach of these documents! Therefore, the County will need to discharge these obligations under the Trust Agreement and the Facility Lease if it desires to change or abandon the Project. -The County can do this only by defeasing the Certificates, as the County does not have the option of presently prepaying the Certificates. However, the County is permitted pursuant to the; Trust Agreement and Facility Lease to defease the Facility Lease and Trust Agreement by depositing with the Trustee federal securities which will generate principal and interest sufficient to pay the principal and interest represented by the Certificates to, their first optional prepayment date (November 1, 2002 for Current Interest Certificates and their maturity dates for Capital Appreciation Certificates) . The federal tax rules applicable to the Certificates require that the "yield" on the federal securities cannot exceed the "yield" on the Certificates. Such a defeasance would result in the discharge of the Trust SF2-31085.1 [O RRICK, HERRINGTON & SUTCLIFFE DeRoyce Bell May 19, 1994 Page 4 i Agreement and Facility Lease, and allow the County to abandon the Project. However, the defeasance probably can only be done at a substantial cost. This cost of defeasing the Certificates results from, first, the difference between the interest rate represented by the Certificates and the interest rate on the federal securities (which cannot exceed the interest rate on the Certificates) prior to the dates of payment of the Certificates, and, second, the cost of recovering the expenditures to date of Certificate proceeds (i.e. , expenditures for costs of issuance of the Certificates and expenditures to date on the Project) . Your financial advisor should be able to help. you estimate the amount of this cost. The County does not have the right to abandon or substantially change the Project in the absence of defeasing the certificates. i Assuming that defeasance and discharge of the Trust Agreement and Facility Lease do not occur, an abandonment of or substantial change to the Project would result in a breach of the Facility Lease. ,l The Certificates represent the rental payments made by the County for the Project, and investors and rating agencies alike have relied on the promises of the County to complete and occupy the Project. In order to satisfy such rating agency and investor requirements, the County covenanted in Article IV of the Facility Lease (and in particular Section 4.01) to acquire, con°struct and occupy the Project. In the event the County were to Abandon.or substantially change the Project, the County would belin a breach of these covenants, and the County would be in default under the Facility Lease and Trust Agreement. We emphasize strongly the continued importance to the County of complying with !its contractual obligations incurred in connection with the sale of securities. r Assuming that the County desires to abandon or substantially change the Project, and protects the Certificate owners by defc4sing the outstanding Certificates, the County should, before proceeding with such a plan, consider the following matters. • The County's current good reputation with the rating agencies has been derived not only from the jfinancial strength of the County, but also the high regard of the rating agencies for the Imanagement of the County. The County would need ,oto consider whether a substantial change in the SF2-31085.1 i QRRICK, HERRINGTON & SUTCLIFFE DeRoyce Bell May 19, 1994 Page 5 Projector abandonment of the Project would affect each rating agency's evaluation of the County's management processes. i • The Project was selected following an evaluation of the alternatives available to the County, to satisfy the County's medical care obligations. Failure to complete the Project, .or the making of substantial changes to the Project, should be adopted as an alternative only after the County determines that the County's financial situation will not be adversely affected by the alternative method utilized for providing health care in the County. • The implication of any change to or abandonment of the Project on future County debt issuances needed to provide necessary County facilities would need to be explored. • Froposed changes to ongoing projects require consideration of whether the secondary market for the securities issued to finance that project would be affected. • Similarly, the effect of a substantial change to or abandonment of the Project on the sale of future obligations of the County would also need to be considered. I hope this letter has been helpful. Please don't hesitate to call me if you would like to discuss any of these matters further. Very trul yours, Thomas R. Shearer, Jr. TRS/eam SF2-31085.1 QRRICK, HERRINGTON & SUTCLIFFE September 24, 1993 Drat Dia! CONTRA COSTA COUNTY 415) 773-5524 RECEIVED DeRoyce Bell Deputy County Administrator SEP 2 91993 County of Contra Costa County Administrator's Office OFFICE OF 651 Pine Street, 1 ith Floor COUNTY ADMINISTRATOR Martinez, CA 94553 Re: County of Contra Costa Certificates of Participation (Merrithew Memorial Hospital Replacement Project) (Series of 1992 Dear DeRoyce: This letter is in response to your questions regarding potential consequences thati should be considered by the County before the County makes any changes to the County's plan for the acquisition and construction of the replacement project for the Merrithew Memorial Hospital (the "Project"). The Project is being financed from the proceeds of the Certificates of Participation discussed below. It is our understanding that the County desires to know what flexibility it has with regard to abandoning or substantially changing the Project. Background County of Contra Costa Certificates of Participation (Merrithew Memorial Hospital',Replacement Project), Series of 1992 (the "Certificates"), in the aggregate principal amount of $125,584,011.80, were delivered to investors on May 13, 19b2. The Certificates were executed and delivered pursuant to a Trust Agreement, dated las of May 1, 1992 (the "Trust Agreement"), by and among the County of Contra .Costa (the "County"), the Contra Costa County Public Facilities Corporation (the "Corporation") and U.S. Trust Company of California, N.A., as trustee (the "Trustee") and evidence fractional undivided interests in base rental payments to be made by the County pursuant to a Facility Lease, dated as of May 1, 1992 (the,"Facility Lease"), between the County, as lessee, and the Corporation, as lessor. Old Federal Reserve Bank Building • 400 Sansome Street • San Francisco,California 94111-3143 Telephone 415 392 1122 • Facsimile 415 773 5759 �F9_'ta�F i Los Anveles • Ncw York . Sacrawc fo • Washington,D.C. I QRRICK,HERRINGTON & SUTCLIFFE DeRoyce Bell September 24, 1993 Page 2 The Certificates were sold to finance the design and construction of the Project, which is-leased to the County pursuant to the Facility Lease. Prior to the completion of the Project, the Certificates are payable from a prefunded rental account held by the Trustee, and following completion and occupancy of the Project.by the County, the Certificates are payable from the base rental payments _ paid by the County pursuant to the Facility Lease. Completion of the Project on time is essential tojthe.security of the Certificates. It is our understanding.-that-the. County Is presently designing the Project. I Additions to the Project not located in the City of Martinez, California are permitted to be financed from the proceeds of additional Certificates of Participation issued on a parity with the outstanding Certificates upon satisfaction of the conditions contained in the Trust Agreement, subject to the condition that the acquisition and construction cost of the additions to the Project do not exceed $20,000,000. Additions to the Project located outside the City of Martinez in excess of this $20,000,000 limit cannot be financed pursuant to the Trust Agreement on a parity with the outstanding Certificates. Issue The issue is, in the event the County determines to change or 11 abandon the Project, what factors should the County consider before proceeding with any change. '!These considerations have both legal and financial impacts, and you should obtain jfrom the County's Financing Consultants comments with regard_ to the financial impacts. Legal Considerations The County has incurred a number of legal obligations to the purchasers of the'Certificates. The Trust Agreement and Facility Lease contain promises of the County which require the County to complete the design and construction of the Project in a timely manner. Any substantial change to the Project, or abandonment of the Project, would put the County in breach of these documents. Therefore, the County will need to discharge these obligations under the Trust Agreement and the Facility Lease if it desires to change or abandon the Project. QRRICK,HERRINGTON & SUTCLIFFE DeRoyce Bell September 24, 1993 Page 3 The County can do this only by defeasing the Certificates, as the County does not have the option of presently prepaying the Certificates. However, the County is permitted pursuant to the Trust Agreement and Facility Lease to defease the Facility Lease and Trust Agreement by depositing with the Trustee federal securities which will generate principal and interest sufficient to pay the principal and interest represented by the Certificates to their-first optional prepayment date (November 1, 2002 for Current Interest Certificates and their maturity dates for'!Capital Appreciation Certificates). Such a defeasance would result in the discharge of the Trust Agreement and Facility Lease, and allow the County to abandon the Project. However, the defeasance probably can only be done at a substantial cost. This cost of defeasing the.Certificates results from, first, the difference between the interest rate represented by the Certificates and the interest to be earned on the federal securities prior to the dates of payment of the Certificates, and,-second, the cost of recovering the expenditures to date of Certificate proceeds (i.e., expenditures for costs of issuance of the Certificates and expenditures to date on the Project). Your financial advisor should be able to help you estimate the amount of this cost. The County does not have the right to abandon or substantially change the Project in the absence of defeasing the Certificates. Assuming that defeasance and discharge of the Trust Agreement and Facility Lease do not occur, an abandonment of or substantial change to the Project would result in a breach of the Facility Lease. The Certificates represent the rental payments made by the County for the Project, and investors and rating agencies alike have relied on the promises of the County to complete and occupy the Project.-'.In order to satisfy such rating agency and investor"requirements, the County covenanted in Article IV of the Facility Lease (and in particular Section 4.01) to acquire, construct and occupy the Project. In the event the County,were to abandon or substantially change.the Project,*the County would be in a breach of these covenants, and the County would be in default under the Facility Lease and Trust Agreement. We emphasize strongly the continued importance to the County of complying with its contractual obligations incurred in connection with the sale of securities. SF9-34SR 1 QRRICK, HERRINGTON & SUTCLIFFE DeRoyce Bell September 24, 1993 Page 4 Assuming that the County desires to abandon or substantially change the Project, and protects the Certificate owners by defeasing the outstanding Certificates, the County should, before proceeding with such a plan, consider the following matters. • The County's current good reputation with the gating agencies has been derived not only-from the financial strength of the County, but also the high regard of the rating agencies for the management of the County. The County would need to consider whether a substantial change in the Project or abandonment of the Project would affect the rating agency's evaluation of the County's management processes. • The Project was selected following an exhaustive evaluation of the alternatives available to the County to satisfy the County's medical care obligations. Failure to complete the Project, or to make substantial changes to the Project, should be adopted as an alternative only after the County determines that the County's financial situation will not be adversely affected by the alternative method utilized for providing health care in the County. • The implication for the change or abandonment of the Project on future County debt issuances needed to provide necessary - County facilities would need to be explored. • Proposed changes to ongoing projects require consideration of whether the secondary market for the securities issued to finance that Project would be affected. • Similarly, the effect of a substantial change or abandonment to the Project on the sale of future obligations of the County would also need to be considered. SF2-3456.1 ®RRICK,HERRINGTON &x SUTCLIFFE DeRoyce Bell September 24, 1993 Page 5 I hope this letter has been helpful. Please don't hesitate to call me or Phil Morgan if you would like to discuss any of these matters further. Very truly yours, rim Thomas R. Shearer, Jr. TRSleam SF2-3456.1 TO: BOARD OF.,SUPERV SORS k Cor Phil Batcheld �County Administrator ti-.` FROM: Mark FinucaneW,, ealth Services Director '`4a .!s CO% DATE: March 2, 1992 . COL SUBJECT: REPORT RECOMMENDING ACTIONS RELATED TO THE CONSTRUCTION OF A REPLACEMENT FOR MERRITHEW MEMORIAL .HOSPITAL SPECIFIC REQUEST($)OR RECOMMENDATION($)&BACKGROUND AND JUSTIFICATION RECOMMENDATIONS: 1, Acknowledge that a number of important steps have been taken by the Board of Supervisors over the past several years which have led to a recognition that it is timely and essential to replace the County's obsolete hospital which is out of. compliance with currently applicable licensing and certification standards . Among the steps which have been taken are the following: A. A needs assessment has been done by Arthur Young and Co. and Stone, Marraccini, and Patterson to determine the initial financial feasibility and cost of replacing Merrithew Memorial Hospital , The Board of Supervisors accepted this report in December 1988 . B. A financial model has been completed by Lewin/ICF which identified the level of financial support necessary to support a replacement hospital. The Board of Supervisors conducted a Workshop on this report on April 41 1989 . C. A market survey has been completed by Lewin/ICF which demonstrated the relative bed size need for a replacement facility. This report was the subject of another Workshop before the Board of Supervisors on April 25, 1989 CONTINUED ON ATTACHMENT: X_.Yis SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE($): ACTION OF.BOARD ON APPROVED AS RECOMMENDED OTHER . v VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE ' UNANIMOUSABSENT ( ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES, AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. CC: County Administrator's Office ATTESTED Health Services Department PHIL BATCHELOR,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR M382 (10/88) BY DEPT D. The Board of Supervisors contracted with Kaplan/McLaughlin/Dias (KMD) , Architects in July 1989 for a master plan and pre-architectural program which identified the program and functional space requirements for a replacement facility. E. The . Board of Supervisors also contracted with KMD, Architects, in February 1991, for schematic drawings to more completely define the layout and exact square footage size for the replacement facility. F. A financial feasibility study was done by the County's financial advisors which determined that it is feasible to finance the project while minimizing the impact on the County's credit rating. 2 . Acknowledge that the solution to the County's longterm hospital needs depends on a cooperative relationship with the private medical community (including the district hospitals) and that the solution which is being proposed presupposes that contracts will be needed both in East and West County, since the size of the hospital, as designed,, is insufficient by itself to meet the County' s needs . 3 . Acknowledge that this cooperative working relationship with the county medical community has already been well documented by a number of activities which have been developed over the last several years The Health Services Department. contracts for over $7 . 5 million worth of services each year with community hospitals and physicians . Among these cooperative services with the private sector (including District Hospitals) are the following: f. A. A joint venture under which Merrithew Memorial Hospital physicians deliver babies for Richmond Health Center patients at Brookside Hospital. From - February 1991 through January, 1992 there were 140 such deliveries . B. The designation of John Muir Medical Center as the regional trauma center for the County,, including an agreement to accept medically stable County patients at Merrithew Memorial Hospital, C. Discussions are nearly complete which will enable the Merrithew Memorial Hospital Family Practice Program and Mt. Diablo Medical Center to develop a private practice rotation. 4 . Acknowledge that steps have been taken to work with East Bay Hospital to determine whether or not that facility can be acquired or a joint venture can be worked out with them which would be to the mutual benefit of the County and East Bay Hospital . 5 . Authorize the County Administrator and Health Services Director and their staffs as well as members of the Board of Supervisors to continue to work with the Board of Directors and staff of Los Medanos Community Hospital District to determine whether a joint venture or other arrangement can be put together which would be mutually beneficial to the County and Los Medanos Hospital . 6 . Authorize the County Administrator and Health Services Director and their staffs as well as members of the Board of Supervisors to continue to work with the Board of Directors and staff of the West Contra Costa Community Hospital District (Brookside Hospital) to determine whether an expanded joint venture or other arrangement can be put together which would be mutually beneficial to the County and Brookside Hospital. 2 7 . Approve the schematic design documents prepared by KMD, Architects, which provide for the construction of a 144 bed replacement hospital which will address the current hospital 's licensing and certification deficiencies and which will assist Contra Costa County in meeting its health care obligation to the patients the County is required to serve. 8 . Approve ithe project and continue the preparation for construction of a 144 bed replacement hospital at a project cost of $,�81.8 million, plus financing costs and the cost of issuancej', including taking the following actions: A. Acknowledge that the financing of the proposed new hospital will come from the following sources : SB 1732 (Chapter 1635, Statutes of 1988) permits hospitals which are disproportionate share hospitals with regard to providing services to Medi-Cal patients to receive, with State approval, supplemental reimbursement to be used for financing the construction, renovation, or replacement of hospital facilities, including buildings and fixed equipment. I SB 855 (Chapter 279, Statutes of 1991) provides for an intergovernmental transfer program whereby counties can provide what would otherwise be the State match for additional federal Medi-Cal dollars, thereby funding an additional payment from the State to hospitals serving a disproportionate share of the Medi-Cal population. The hospital will be funded as follows : 'SB 1732 = 52% SB 855 = 36% ` Medicare= 12% , TOTAL = 100% B. Authorize the County Administrator and Health Services Director to negotiate and present to the Board ' of Supervisors for approval the final Consulting Services Agreement with KMD, Architects, to prepare the necessary construction documents which will qualify the project for state funding within the deadline established pursuant to state: law (SB 1732, Chapter 1635, Statutes. of 1988) . C. Authorize the County Administrator and Health Services Director to negotiate and recommend to the Board of Suvekvisors the selection of a Construction Management firm (CM) which would work with the architects and which would assist the County in project management and the selection of construction contractors . In addition, the CM will assume the responsibility for helping to control costs., provide value engineering,, provide for testing the quality of materials and oversee the standards of construction. D. Direct the County Administrator to work with the Auditor- Controller, Treasurer-Tax Collector and .financial consultants to take the steps which are necessary to provide for borrowing of the necessary funds at the currently advantageous interest rates which are the lowest in over 20 years. E. Authorize the County Administrator, Auditor-Controller, and Treasurer-Tax Collector to work with the County's legal and financial advisors and rating agencies in New York to secure the necessary funds for this project. 9 . Authorize , the County Administrator and Health Services Director to negotiate with the Martinez Unified School District for the joint development of parking at Alhambra High School which could be used by the staffs of both the school district and Health Services Department and direct General Services staff to submit appropriate information to the City of Martinet . 3 10 . Direct the County Administrator and Health Services Director" Fv a to work with the appropriate financial advisors, state administration and legislative representatives to insure that this County and other counties are able to retain reimbursement funding from the state pursuant to SB 1732 . 11 . Direct the County Administrator and Health Services Director to work with the appropriate financial advisors, the federal administration and legislative representatives to insure that this County and other counties-': are able to retain reimbursement funding from the federal government from Medicare funds pursuant to existing provisions of law which authorize the Medicare Program to reimburse hospitals for their capital costs . 12 . Authorize the Health Services Director to actively support legislation being sponsored by the National Association of Public Hospitals which would provide funding for additional construction, bond insurance and related costs in order to recapitalize public hospitals in the United States . 13 . Direct the County Administrator and Health Services Director to take the steps which are necessary to set aside from SB 855 funds for the first five years of the project, beginning with the 1992-93 fiscal year, $3 .5 million per year to establish a project reserve fund. 14 . Direct the County Administrator and Health Services Director to take the steps which are necessary to set aside from SB 855 funds, after the establishment of the project., reserve fund described above, the sum of $3 . 5 million per year for the remaining life of the project to provide for the retirement of outstanding debt. 15 . Direct staff to return to the Board of Supervisors with the legal documentation that will provide for the sale and issuance of debt for the replacement project. 16 . Direct the Health Services Director and Executive Director, Merrithew Memorial Hospital and Clinics, to form a Martinez Community_ Advisory Committee, consisting of representatives from the community and immediate neighborhood, the City of Martinez and the Martinez Chamber of Commerce, to advise the Health Services Director and Executive Director, Merrithew Memorial Hospital and Clinics, on the project's impact on the City and particularly on the immediately surrounding neighborhood. 17 . Authorize the Health Services Director to' designate an employee of the Health Services Departmentto serve as an Ombudsman during the construction period to receive and resolve all issues and questions which arise from the public regarding the construction program. 18 . Direct the Health Services Director and Executive Director, Merrithew Memorial Hospital and Clinics, to form a Construction Project Advisory Board, consisting of Health Services Department staff, to advise the Executive Director, Merrithew Memorial Hospital and Clinics, on the management of this building program, while simultaneously occupying the existing facility and planning for the transition to the new facility. 19 . Direct the County Administrator and Health Services Director to hold regular meetings of the project oversight committee, which was created by the Board of Supervisors in 1987, is composed of representatives from labor, advisory boards, members of the Grand Jury, other hospitals in the community, the Taxpayers ' Association and various County staff, and which has held some 17 meetings since 1987, for the purpose of insuring that the Board' s policies in regard to this project are fully implemented. 4 20 . Direct the County Administrator and Health Services Director to work with members of the Board of Supervisors to explore the feasibility of entering into a joint venture or other arrangement with the Department of Veterans Affairs. In this regard, a' meeting is scheduled for March 10, 1992 with County representatives and David Lewis, Assistant Secretary of the Department of Veterans Affairs for Acquisition and Facilities, to, discuss the joint' venture first proposed by the County in September 1991. In connection with this recommendation, direct the County Administrator and the Health Services Director to report the results of this meeting to the Board .of Supervisors on March 17, 1992 with modifications, if any, to this report which may be desired as a result of the meeting with Assistant Secretary Lewis . 21 . Direct the County Administrator and Health Services Director to make periodic reports to the Board of Supervisors, on the status of the financing and construction of the replacement hospital . BACKGROUND: In 1986, the Board of Supervisors requested the Health Services Department. to undertake a comprehensive review aimed at replacing Merrithew Memorial Hospital, including strategic, architectural and financial planning studies . Numerous reports have been issued over the past six years concluding that Merrithew Memorial Hospital is outdated and needs to be replaced. It has been suggested from time to time that the Board of Supervisors contract out all inpatient care to hospital district and/or private hospitals and simply close the County Hospital. However, neither the public nor private sector alone can meet the growing health care needs of all residents of Contra Costa County. A joint effortis required. The- current proposal to replace Merrithew Memorial Hospital is a blended solution: a new scaled- down hospital in conjunction with expanded contracting. The County population has more than doubled since the late 1950 's, when much of the current facility was built. Yet, the hospital will actually be smaller than, the current facility in terms of bed capacity. This proposal is consistent with recommendations from the 1988-89 Grand Jury, ' which called for a combination of replacing the hospitCal. and. contracting as the best way to ensure health services in a large and growing county. Relying totally, on contracting to meet 100% of the demand would simply not work ' for the following reasons : discussions over the last decade attempting to develop comprehensive contracting proposals with other hospitals and their physicians in the County have not been successful . although some hospitals may have empty beds, they are either unwilling or unable to care for AIDS DS patients, jail inmates, psychiatric patients, indigents, or even Medi-Cal patients. negotiations have, however, resulted in a successful Joint Venture with Brookside Hospital to deliver babies . This is the first time in the history of the Health Services Department that county physicians have been granted privileges and are admitting patients to a non-county hospital . Similar discussionsare underway with Los Medanos Hospital. The Health Services Department is counting on such contracts in proposing a smaller hospital . These contracts will not, however, do,, away with the need for a new hospital. With the recent closure of the Veterans Administration Hospital in Martinez, it has been suggested that the County hold off taking any action to construct a new hospital until it can be determined whether a joint "venture can be developed with the Department of Veterans Affairs, A delay is unnecessary. While a Joint Venture with the Department of Veterans Affairs would be highly desirable, 5 such a proposal is complicated and may not be achievable within the realistic funding deadlines which are facing the Board of Supervisors. The Department of Veterans Affairs has finally indicated a willingness to explore the possibility of a joint venture with the County. This meeting will take place on.March 10, 1992 . Discussions with the Department of Veterans Affairs can and will take place at the same time that the construction plans are being developed. It has also been suggested that the hospital serving the indigents of the County .should be located either in East County or West County in .order to be more convenient to residents of those" areas . The current site in Martinez appears to be the most appropriate location for several reasons : * Martinez is centrally located. * The largest percentage of Merrithew Memorial Hospital ' s patients come from Central County. * Contra Costa County already owns the land for the proposed hospital, thereby substantially reducing the projected cost of a replacement hospital . * All hospital support services and psychiatric inpatient services will remain on the current campus . Locating the hospital elsewhere would necessitate moving these services as well at a substantial increase in cost. In addition, Merrithew Memorial Hospital specializes in care that is often not available through the County. The Health Services Department has developed considerable expertise in four areas that will continue to be the focus of the hospital : AIDS, inpatient psychiatry, geriatrics, and obstetrical care for Medi-Cal patients . Because these services are regional in nature, a centrally-located facility enables residents from all parts of the County to have access to this care. It has also been suggested that there is no real need to replace the hospital at all; more of an emphasis on outpatient clinic care would substantially decrease the need for inpatient care. Merrithew Memorial Hospital is one component of the Health Services Department' s comprehensive health care system that includes public health and prevention, ambulatory care and home health care. Without a hospital, the network of services will become fragmented and the continuity of care will be seriously disrupted. At the same time that the Health Services Department is proposing to replace the hospital, the ambulatory care system is being expanded. The Board of Supervisors has strengthened the clinic system by dedicating $5 .7 million to its operation. Other recent. efforts in support of an increased outpatient presence include: * opening an Older Adult Clinic in West County and pursuing another one in Antioch. * Relocating . and. expanding geriatric outpatient services in Central 'County. * obtaining additional outpatient clinic space from Los Medanos Hospital . * adding 29 new employees to the ambulatory care clinics over the last 2 years . * increasing the number of visits to the clinics by an expected 14 ,500 from 2 years ago. * Expanding specialty care at the Martinez site. At times it has also been suggested that the public sector is getting out of the hospital business and therefore Contra Costa County has no business replacing its hospital. However, the fact is that Contra Costa County is far from being alone in seeking to replace its hospital . Because public hospitals throughout California - and the United States - have been neglected during .the past several decades, many are in a comparable state of disrepair 6 to Merrithew Memorial Hospital . Virtually every major county in California has embarked on hospital replacement and refurbishment programs because of the tremendous needs and because of the recent availability of funding through SB 1732 . In addition, the National Association of Public Hospitals is spearheading a capital financing legislative initiative, supported by public hospitals and local health agencies from all regions of the country. The proposed replacement of Merrithew Memorial Hospital is significantly smaller than those of other counties of comparable size, indicating again the extent to which Contra Costa County already contracts with community hospitals to provide care. For instance: * Fresno County, with a population of 667 , 000 is proposing the replacement of their 300-bed county hospital . * Riverside County, with a population of 1, 170, 000 is proposing the replacement of their 362-bed county hospital . * San Joaquin County, with a population of 481,000 (only slightly more than half the size of Contra Costa County) is proposing,, the replacement of their 223-bed county hospital . Some will no doubt express concern with the thought of building a hospital with the state of the economy currently and the fact that the State has a substantial deficit, which will undoubtedly have some impact on the County. However, the new hospital will be totally financed by state and federal funds . No County General Fund revenues are anticipated to be needed for the project. Nearly two-thirds of these funds can only be used for capital improvement projects . These funds are not discretionary and would not be available to the Board of Supervisors for other health care services or for other services outside of the health care field. Assuming approval of the above recommendations by the Board of Supervisors today, the following is the estimated schedule for completion of various phases of the project: March 3, 1992 Board of Supervisors authorizes staff to proceed with plans and financing. March 9, 1992 Architects proceed with final plans . March 24, 1992 ` Board of Supervisors is asked to approve legal documents for the financing of the project March 26/27, 1992 Rating agency meetings in New York. April 10, 1992 Rating received. April 29, 1992 Financing issue closes and funds are available. September 1992 Design Development documents are completed. May 1, 1993 Construction documents are completed. May 1, 1993 Final plans are filed with the State. August 1, 1993 Break ground for pre-construction site work. May 1, 1994 State review is complete. June 30, 1994 SB 1732 filing deadline. July 1994 Replacement Hospital construction begins . March 1997 Construction completed , begin occupancy. 7 April 1998 First debt service principal payment is due. The schedule for repayment of the replacement hospital debt (a copy,,.,, of a typical repayment schedule is included in the attachments to this report) shows the following: BASIC CONSTRUCTION COSTS $ 68,500,000.00 CAPITAL EQUIPMENT X13,300,000.00 SUB-TOTAL $ 81t8001000-00 FINANCING $ 301900-r000-00 ISSUANCE $ 11300,000-00 TOTAL PAYMENTS ON THE PRINCIPAL* $114,,0001000.00 TOTAL PAYMENTS ON INTEREST $135, 977,087 .50 GROSS DEBT SERVICE $249 ,977,087 .50 EARNINGS ON DEBT SERVICE RESERVE FUND ( $ 28,470,544 .43) CAPITALIZED INTEREST ($ 38, 105, 163 .93) NET DEBT SERVICE $183,401,377 . 14 *Includes project construction costs, plus cost of financing and issuance costs . =n Lewin//CF, a division of Health and Sciences Research Incorporated J � i r, April 21, 1989 i Mr. Mark Finucane Health Services Director; Contra Costa County Health Services Department 20 Allen Street Martinez, California 94553 Dear Mr. Finucane: , Lewin/ICF is pleased to provide you with this letter report on market and financial analyses for a replacement facility for Merrithew Memorial Hospital (the Hospital) . The report is organized into "the following sections: • The questions Lewin/ICF addressed; • Lewin/ICF approach; ■ Background utilization information; • Utilization projections and scenarios of bed need; A. Utilization model methodologies. ; B. Results of utilization scenarios; • Revisions to- the Arthur Young (AY) financial model; ■ Financial results of utilization and new hospital scenarios; and, • Other potential utilization scenarios considered. 5028 Geary Boulevard 0 San Francisco, California 94118 2 415.668.2902 Mr. Mark Finucane April 21, 1989 Page 2 Our report contains utilization estimates and financial projections of the net County contribution for the Hospital for the seven years ending June 30, 1989 through 1996. As you are aware, we depended heavily (particularly for financial data and assumptions) an Health Services Department staff, on the Department's architects, Stone, Marraccini, and Patterson (SMP) , and on a financial model prepared by Arthur Young and modified by us in the preparation of these analyses. While we are confident that these analyses fairly represent the range of potential outcomes from replacing the Hospital facilities, actual results will vary from the projections and the variations may be material. In our opinion, the analyses are based on reasonable assumptions which reflect currently available information on expected utilization and financial performance of the Hospital. As you may be aware, these analyses have been prepared for your internal decision makin& about replacing the hospital. Additional analyses will need to be prepared for the financing documents and the architectural planning which we understand will be starting shortly subject to Board of Supervisors' approval. The analyses of Merrithew's market for patient services resulted in a range of projected beds needed for the replacement hospital. This. range in the estimated number of beds needed, from 190 up to 234 beds, is based on differing levet+s of Merrithew market success and ability to manage and potentially reduce inpatient lengths of stay. The financial model was used to assess financial implications of the capital and operating costs associated with replacing the Hospital facilities. A number of financial scenarios were developed, including four which reflect various replacement hospital bed sizes, two which incorporate optimistic and pessimistic financial (versus only bed size/utilization) assumptions, two scenarios wherein the County does not replace the Hospital but invests to correct deficiencies in the current facilities, and one final "worst case" scenario whichldemonstrates the extent of financial exposure which could occur if both market and financial position deteriorate significantly. The "bottom I 4 Mr. Mark Finucane April 21, 1989 Page 3 line" measure/output from the financial model is the amount of County subvention needed to maintain the hospital's operations at the break-even level. This amount was determined by Health Services Department staff to have been approximately $6.2 million in fiscal year 1988. r The results of the financial analyses, which are described in more detail in the attached report, are summarized in the table presented on the next page. The results show that the financial support provided by the County to the Hospital, if the facilities are replaced, could increase from the $6.2 million for 1988 up to a range of $11.8 million to $19.5 million for fiscal year 1996. 4 G I � _ � .... ._ _�... _ .. _.�+^..,sf�sq,.,'�'ti`."_`� ._�-'.}...`ice _ :.i£�:i.'•;o:�e:�:':i_�£.f£#,iEka,x�e 3:.ft.fL.,., ...... ,.... _ .. ` t Mr. Mark Finucane April 21, 1989 Page 4 Merrithew Memorial Hospital Results of Financial Analysis Project Cost County Contribution (000s) Scenario MOOS)* 1992 1996 A - Business as Usual $88,788 $8,476 $13,823 B - "Good" Market 96,701 8,481 14,918 C - "Bad" Market 83,406 9,462 15,579 D - Business as Usual with 84,345 8,176 11,808 Aggressive Utilization Management Business as usual, with optimistic financial assumptions 88,788 5,676 10,015 Business as usual, with pessimistic financial assumptions f 88,788 8,672 17,936 Business as usual, remaining in the current facility 12,000 8,642 9,737 Aggressive utilization management, remaining in the current facility 12,000 8,382 8,843 I "Worst" case scenario 88,788 9,411 19,451 *Source of project costs: Estimates by Stone, Marraccini, and Patterson (the County's original architectural consultants) and Department of Health staff. Note: The estimated County contribution for Merrithew in fiscal year 1988 was $6,202,000. The two final scenarios, in which the County does not replace the i Hospital, but corrects currently known deficiencies in the facilities at a 1 Mr. Mark Finucane April 21, 1989 Page 5 cost of $12 million indicate that, given the achievement of the projection assumptions, the County contribution could increase to $8.8 to $9.7 million by 1996. I� We have enjoyed working with the Contra Costa County Health Services Department and appreciate the efforts your staff has provided in the preparation of these analyses. I' i I S ely, I A. on V cue President Joan Meisel Vice President it ISI i i4 4 I' I I ...:..,. -.:�:s�_`.+..._<M'+..,�.;��envkfi�.s.`t `z'ra,,'.-+y`�.�.;eoa.}cc�ti'�,. •'.xo-Cwaiiz��•titi+t,^�c�•'''. i .. ... _... _ l _ �ARKFi' AM IFTNANCIAL ANALYSES OF A REPLACEKWT HOSPITAL FACILITY FOR i CONTRA COSTA COUNTY 'i This rep--rt summarizes market demand and financial projections prepared by Lewin/ICF, with the assistance of the Contra Costa County Health Services Department, forianalyses of replacement facilities for Merrithew Memorial Hospital. I THE QUESTIONS LEWIN/ICF ADDRESS `was asked to address the following questions regarding Lewin/ICF � g replacement ofthe Hospital facilities: I • I What size replacement hospital would be needed to meet the range in anticipated demand for inpatient services by the year 2000? r • Whatliis the expected range of fiscal impacts on the County contribution to Merrithew if the Hospital facilities are completely replaced? Lewin/ICF was not asked to examine other potential strategies for providing I inpatient services to County residents, nor to comment on the County's capacity to finance the Hospital facilities replacement project or the alternative mechanisms for financing a new facility. I"IN/ICF APPROACH To complete these analyses Lewin/ICF undertook the following steps:s: 1. Examined trends evident in historical patient volumes, historical and projected demographics of Contra Costa County residents, and the use of hospital services by various subsets of the County population; r II I 2 . 2. Developed utilization projections to determine the number of hospital beds needed at Merrithew, using a methodology and model reflective of Merrithew's unique payer mix, compliment of current and planned patient services, and potential impacts of the new hospital facilities; 3. Reviewed and revised the Hospital's financial planning model (developed by Arthur Young) and assumptions; and, 4. Prepared a series of utilization and financial scenarios to demonstrate the range of financial impacts on the County from differing levels of market success and resultant new hospital sizes. The results; of this work program are presented below. BACKGROUND UTILIZATION INFORMATION Market demand projections are typically prepared by examining four principal determinants of any hospital's inpatient utilization, namely the number and demographic characteristics of service area population, discharges per 1,000 persons (use rates) , market shares, and hospital specific lengths of stay. Recent historical trends and available projections for these demand components form ;the framework for developing utilization estimates, and are reviewed below. 1. Overall Utilization Trends. Table 1 summarizes Merrithew historical and fiscal year 1989 estimated discharges, average lengths of stay, and patient days for two categories of inpatient services: general acute and psychiatric. IS. 3 Table 1 Historical and Estimated 1989 Inpatient Utilization Years ended June 30. Estimated 1985 1986 1987 1988 1989 Discharges General acute 5,800 5,672 5,690 6,041 6,306 Psychiatric 1.718 1:565 1.399 1.203 1.010 Total 7,518 7.237 7.089 7,244 7,316 Average length of stay General acute 5.00 4.93 5.03 5.33 5.19 Psychiatric 7.69 7.82 8.79 11.98 14.61 Overall hospital 5.61 5.56 5.77 6.43 6.49 Patient days General acute 28,996 27,987 28,605 32,199 32,738 Psychiatric 1 13.217 12,244 12.303 14.412 14.755 Total 42,213 40,231 40,908 46,611 47,494 Source: Hospital records and MMH management estimates for 1989. The data indicate that general acute patient days have increased 12.9 percent from 1985 to 1989 to an average daily census of 89.7 (32,738 days/365) while psychiatric days' have increased by 11.6 percent to an average daily census of 40.4 (14,756 days/365). The primary factor in increased psychiatric census has been an increase in lengths of stay, which is generally explained by difficulties in placing psychiatric patients who no longer require an acute patient care setting. A graphical representation of the information in Table 1 is included in the Appendix as Exhibit 1. 2. Utilization and Market Shares by Paver. Table 2 presents combined general acute and psychiatric discharges and market shares for key Merrithew payers. It is important to analyze Merrithew's patient volume/market information by payer class, because the degree of competition for patients 4 - differs for eachjlpayer. For example, many hospitals in Contra Costa County compete aggressively for patients with private insurance, since reimbursement for hospital care of private insurance patients is good, whereas Merrithew faces little competition for its self-pay (indigent) patients. During recent years, the Hospital's percentage (market share) of all county residents who are hospitalized ,!with Medicare and commercial insurance health care coverage has declined, while gains have been realized in Medi-Cal. If discharges for Medi-Cal enrollees in the Contra Costa Health Plan (CCHP) were included in the market share estimates, displayed 1989 Medi-Cal market shares would increase to approximately ,33.0 percent. i Table 2 Merrithew Memorial Hosgital Patient Volumes and Market Shares Years Ended June 30. j ZQ86 1989 Percent Change Discharges Medicare 1,236 1,052 (158) Medi-Cal 2,204 2,558 16 Health Plan 572 714 25 Commercial Insurance 503 322 (36) BAC-MIA 1,488 1,240 (17) Private pay 799 1,048 31 All other 435 382 (12) Total 7,237 7.316 Selected Market Shares Medicare 5.3 3.9 Medi-Cal (General acute, non-prepaid) 24.9 27.5 Commercial insurance 2.2 1.6 Source: Hospital records and Merrithew Memorial Hospital estimates; Lewin/ICF estimates. 3. Population Projections. According to projections developed by the California Department of Finance, Llatween 1985 and 2000, the population of Contra Costa County is expected to increase by approximately 153,000 persons, f • 5 - or at an annualized rate of 1.3 percent. About 86.7 percent of this anticipated growth is projected to occur in HFPA 411, the Health Facilities Planning Area encompassing the eastern and central sections of the County. HFPA 413, comprised of Richmond and other western parts of the County, is ex;.,ected to grow by 20,000 persons (an annual rate well below that of California). Table 3 also indicates that the proportion of the population older than 65,years, while lower than the state average in 1985, is expected to increase significantly and actually surpass the state's proportion by the year 2000. Table 3 Contra Costa County Demographics Annual 'Growth X85 1990 1995 2000 1990-95 1995-2000 Population(*) Contra Costa 714,834 766,065 822,132 867,794 1.428 1.09% HFPA 411 (East) 526,080 568,540 616,375 658,713 1.638 1.348 HFPA 413 (West) 188,754 197,525 205,757 209,081 1.828 0.328 California 26,063 28,469 30,654 32,551 1.498 1.218 (in thousands) Percent >65 Years Contra Costa 10.3 11.7 12.5 12.8 HFPA 411 9.8 11.2 12.0 12.3 HFPA 413 11.6 13.1 14.0 14.2 California 10.8 11.5 11.8 11.7 Source: California Department of Finance Note: (*) HFPA — Health Facilities Planning area. 4. Hospital' Use Rates. The final component of historical utilization is use rates, or discharges per 1,000 population. Table 4 summarizes use rates derived from information maintained in various databases on California hospitals. The rates were calculated by summing discharges from hospitals 6 located in Contra Costa County and the state and dividing these totals by Contra Costa County and California population/1,000. The following trends emerge from this information: • Use rates Rarticularly for the population aged less than 65 years. continue to decline in both the County and the state. The decline in recent years can be attributed to several factors, including pressures from third-party payers to minimize unnecessary admissions and the introduction of new technology which allows more procedures to be 'performed on an outpatient basis. ■ The decline in use rates for the elderly appears to be leveling off. This finding likely reflects the continued increases in the average age of the 65 years and older population group. Patients aged 75 to 84 years and those older than 85 use hospital services even more often than the 65 to 74 population age group. ■ Psychiatric use rates appear to be fairly stable. Apparent outmigration from the County for psychiatric services complicates the understanding of these numbers, but there is no reason to assume a fundamental change in this use rate. 7 - Table 4 Hospital-Based Use Rates (Discharges ver 1.000 Persons) _ Years Ended December 31. Estimated 1984 1985 1986 1987 1988 Contra Costa County General acute services 109.9 104.1 102.3 101.1 99.9 Psychiatric services 6.2 6.3 6.2 5.9 5.8 Over 65 years of age 316.0 291.0 283.3 284.0 284.0 Under 65 years of age 93.7 89.7 87.8 85.7 83.7 California General acute services 118.2 113.6 110.5 108.3 104.1 Psychiatric services 5.1 5.1 5.2 5.3 5.3 Over 65 years of age 322.2 306.2 299.1 284.1 282.0. Under 65 years 'of age 93.8 91.5 90.0 88.3 86.6 Sources: OSHPD; Datis, Inc. ; and Lewin/ICF estimates. We have included four graphs displaying this information in the Appendix as Exhibit 2. UTILIZATION PROJECTIONS AND SCENARIOS OF BED NEED This section first describes the utilization model projection methodologies and then presents the results of four utilization scenarios. A. Utilization Model Methodologies As previously mentioned, a detailed, Merrithew-specific methodology and model to project bed need for the replacement hospital facilities was developed. The model was constructed to project volumes for each payer class for both general acute and psychiatric services. The approach used for each payer category is described below. As previously mentioned, it is important L , • y�r 8 - to develop assumptions and utilization projections for each payer, because the degree of competition for patients is different for each payer class. ■ "Market Based" Models: Medicare, private insurance, and general acute Medi-Cal volumes were projected based on trends in use rates, market shares of patients hospitalized in the County by payer source; and in- and out-migration to/from the County for the services. The "market-based" approach was used for these payers because significant competition exists for patients with these types of health care insurance coverage, while for other payers, including indigent patients, providers do not actively seek to attract patients. ContraCostaHealth Plan: Separate ?rojections were made for enrollee growth for each payer class represented within the Health Plan [Medicare, Medi-Cal, Private (including County enrollees) , and BAC/MIA] . Health Plan enrollee hospitalization rates were based on historical patient days per enrollee, except for BAC/MIA discharges, for which measures of discharges per enrollee are not meaningful. Discharges for BAC/MIA patients were projected to increase slightly less rapidly than the County population, commensurate with recent historical experience. Other Pavers: Short-Doyle Medi-Cal and "straight" Short-Doyle were projected based on Merrithew's assumed market share of the County psychiatric Medi-Cal market, which has declined in recent years due to the introduction and increased activity of competing providers (East Bay and Walnut Creek hospitals) and the constraints on additional admissions at Merrithew caused by beds being occupied by patients no longer needing an acute level of care. All other services, such as private pay, outpatient visits, and interdepartmental patients, were projected based on observed historical trends. .:.'`:�,'srzc.;.�ro,�c'.Kt;.',:oz:+ca.:i:cia:.c..-:cGsr....%nA. ..>u.s.. _ ..___....r::;zczs•,:�•.ti,s......':da3s'r..».re...r.. ._. ' • 9 - Few/Developing Programs; The utilization projections also include the effects of further development of the following programs: •• the current Hospital geropsychiatric program, which according to the County's director of Mental Health services could potentially increase from an average daily census of 6 patients up to 14; -- an additional eight beds for adolescent psychiatric services, which would be constructed, staffed, and utilized only if reimbursement for patient care were made available; and -- an increase in census for AIDS patients from the current two to nine patients, commensurate with assumptions and detailed analyses contained in Arthur Young's work. According to Health Services Department staff, the AY-developed assumptions are reasonable to include in these updated analyses. Effects of the New Faciligies. The scenarios also reflect potential effects from the increased capacity and improved amenities of the new hospital facilities. These effects include additional enrollment in the CCHP, particularly for employees of small private enterprises who, according to Health Plan representatives, have been sensitive to the drawbacks of the current facility. The new hospital, in these scenarios, would also generate slight improvements in market share for Medicare. Medi-Cal, and private insurance, and would provide additional capacity for psychiatric services. The additional market shares which were assumed to result from the new hospital were included at-levels which would return the Hospital to market share levels it achieved in recent years, or an increased share of 0.75 percent for Medicare and 0.85 percent for private insurance. Thus these projections contain only a moderate impact from the new facility itself. • 10 - B. Results of Utilization Scenarios Through adjusting the assumptions described above, four scenarios of projected bed need for the replacement hospital were prepared as follows: • Business as Usual (Scenario A): Which reflects a continuation of recent 4eclines in market shares for certain favorable payers such as Medicare and private insurance, increased shares for Medi-Cal inpatient services, slight declines in non-Medicare use rates, fairly'conservative additional patient volumes from new program development, and constant lengths of stay at estimated fiscal year 1989 levels. ■ "Good"Market (Scenario B) : Which demonstrates the potential yield from. the prevention of further market share erosion for private insurance and Medicare, additional success in marketing to Medi-Cal beneficiaries, and increased activity from programmatic initiatives. ■ "Bad" Market (Scenario C) : Reflecting more substantial declines and/or reduced gains in market shares than reflected in Scenario A. • Business as Usual with Aggressive Management of Lengths of Stay (Scenario D) : Contains the same assumptions as scenario A, with reduced lengths of stay for general acute and psychiatric Medicare patients as well as Short-Doyle funded patients. Reductions in lengths of stay for these payers, in particular,. provide significant financial benefits, since reimbursement is either a fixed allocation (Short-Doyle) or paid on a per case/discharge basis (Medicare) where the increased expenses of an abnormally long length of stay are not reimbursed and serve to reduce income. Table 5, below, summarizes the results of these scenarios. Additional details on assumptions for these scenarios are included in the Appendix as Exhibit 3. Table 5 Merrithew Memorial Hospital Summary of Projected Bed Need (in the Year 2000)* Business as Usual with Aggressive Business 'Goods 'Badu Length of Stay as Usual Market Market Management Lai M Patient Days General Acute 42,243 50,234 41,622 44,045 Psychiatric 19,523 21,581 18,226 13,387 Average Daily Census General Acute 124 138 114 121 Psychiatric 53 59 50 37 Projected Bed Need General Acute (@ 808 occupancy) 155 172 143 151 Psychiatric (@ 958 occupancy) lk L. lu R Total 211 234 196 190 *These results do not include the potential effects of one or more providers terminating their participation in Medi-Cal. In all scenarios, projected bed need is derived by dividing projected average daily census (calculated as patients days divided by 365 days) by target/desired occupancy levels for the new facility, which were assumed to be 80 percent for general acute services and 95 percent for psychiatric patients. These are the target occupancy levels generally used in planning studies for sizing inpatient facilities, and are designed to accommodate the variability and seasonality of patient volumes. The results indicate a range of projected bed need from 190 to 234. The next sections of this report present the financial impacts of differing capital and operating costs resulting from the four scenarios. 12 - REVISIONS TO THE ARTHUR YOUNG FINANCIAL MODEL Lewin/ICF made a number of technical corrections and changed several assumptions in the Arthur Young financial model (all with the concurrence of Department of Health staff). The changes were made because Lewin/ICF was asked to update the financial model for new information developed since Arthur Young completed its work and to review the model for its accuracy in projecting the financial consequences of ,a range of bed need and construction costs. Several of these changes resulted in increased levels of projected County subvention for Merrithew, while others improved projected results. The most significant adjustments are discussed below: • Health Services Department staff updated the base fiscal years 1988 and 1989 financial information, to reflect accurately the starting point for assumptions governing 1990' through 1996 projected financial performance. • Model logic calculating Medicare reimbursement was changed to reflect more appropriately the negative financial consequences of increased lengths of stay for Medicare patients. Lengths of stay for Medicare were assumed in the AY model to be approximately 8.9 days in all years, versus the 12.6 days experienced in fiscal year 1989 and projected in the Business as Usual scenario, thus overstating Medicare payments by approximately 40 percent, while understating expenses. ■ The AY modeling determined Medicare reimbursement for capital related expenses partially on the basis of prospective rates per discharge, a methodology which has been delayed until 1991/1992. In addition, the AY model did not include Medicare reimbursement for net interest expense of the bond issue obtained to finance construction. ■ Finally, the AY model included Presley funding (S.B. 1732) based on a constant 45 percent factor, representing the percentage of total - 13 - patient days that are Medi-Cal, applied to project capital related expenses. The model logic was adjusted so that the percentage of capital expense financed by Presley funds would vary with actual assumed Medi-Cal utilization. Lewin/ICF and the Health Services Department staff are confident that the financial model', with these and several other adjustments, provides more reasonable estimates of the financial impacts of the hospital facilities replacement project. FINANCIAL RESULTS OF UTILIZATION AND NEW HOSPITAL SCENARIOS Financial results, which are not presented in current dollars, i.e. , not adjusted for the impact of projected inflation, of the four utilization scenarios (A through D from Table 5) are presented in Table 6 below. Table 6 Merrithew Memorial Hosvital Financial Results of Utilization Scenarios Project Cost County Contribution_ (OOOs) Utilization Scenario (000s)* 1992 1996 A - Business as, Usual $88,788 $8,476 $13,823 B - "Good" Market 96,701 8,481 14,918 C - "Bad" Market 83,406 9,462 15,579 D - Business as Usual with 84,345 8,176 11,808 Aggressive Utilization Management *Source of project costs: Estimates by Stone, Marraccini, and Patterson (the County's original architectural consultants) and Department of Health staff. Note: The estimated County contribution for Merrithew in fiscal year 1988 was $6,202,000. r x- 14 - The financial projections are based on many assumptions (perhaps 150 to 200), including charge and reimbursement rate increases, inflation rates, fixed and variable staffing levels, various hospital replacement project cost levels, and other revenue and .xpense relationships. A detailed list of all assumptions used in the financial siodel is included in the Appendix. Assumptions that are most significant to the projections are discussed below; • Hospital replacementRroiect costs were based on original SMP cost estimates, which totaled $95.1 million, According to SMP, construction and project-related (architects, etc.) costs for general acute and mental health beds would vary directly with the number of beds to be constructed. This assumption was needed to reflect the changed project costs resulting from the scenarios of differing levels of projected bed need. General acute bed project costs were thus based on a cost of $368,000 per bed, and psychiatric beds on a cost of $148,000 per bed. Central plant and outpatient costs were not adjusted from original levels as bed size changed. • Hostiital charge rates per patient day and per outpatient visit were increased 5.0 percent annually from 1990 to 1996, commensurate with overall projected expense inflation rates. • Medicare payments per discharge were increased by 1.5 percent for fiscal years 1990 to 1991, 2.0 percent in 1992 and 1993, and 2.5 to 3.0 percent thereafter. Capital payments, after determining the Medicare share based on utilization and patient charge information, were reduced by 25.0 percent from 1991 through 1996, reflecting current expectations for Federal policy changes commencing in fiscal years 1990/1991. • Medi-Cal rates per patient day were increased 4.5 percent annually, a rate slightly lower than projected overall inflation but reflective of Merrithew's strong bargaining position compared to other, less significant providers of Medi-Cal services. ins` ., , •' ,�,, . 15 - • Short-Doyle funding was assumed to increase with additional adolescent and other psychiatric volumes, based on the assumption that the Hospital would not increase its capacity to treat additional patients unless funO Ong were made available. If the assumption that Short-Doyle funding would vary with volume were changed to reflect the current basis for changes in Short-Doyle funding, which is a fixed allocation adjusted for inflation, the County contribution in the scenarios presented in Table 6 would increase by approximately $1.6 million. • Inflation rates varied from 4.4 percent for salaries to 5.0 .percent for supplies and other variable expenses. Nursing registry expense and malpractice insurance were assumed to increase at 5..0 to 6.0 percent, resulting in overall inflation of approximately 5.0 percent. • Presley funding was based on the percentage of projected patient days covered by Medi-Cal. These projected percentages were applied to total capital related expenses (interest, depreciation, and amortization of financing costs) . Though we understand that the Presley percentage would be applied only to interest and principal payments after project completion, Health Services Department staff considered basing the funding on capital related expenses provided a more reasonable estimate of the average long-term support for the project which would be provided through this state initiative. Thus the actual cash estimated to be received in fiscal years 1995 and 1996 from the Presley initiative could be up to $1.3 million less than that included in the presented results. These levels would be received, however, in later years depending on the actual structure of debt service payments. The Appendix in Section 4 contains detailed schedules reflecting the assumptions and results of these scenarios. 16 - Additional Financial and Utilization Scenarios In addition to the four scenarios described above, we also analyzed two additional sets of scenarios: • adjustments to financial (versus the utilization) assumptions; and • two scenarios wherein the County invests $12 million to correct currently known deficiencies in the existing facilities and does not replace the Hospital. Results of these additional four models are presented below in Tables 7 and 8. Major assumptions changes for each of the four scenarios in Tables 7 and 8 are presented below: • Qptimistic Financial Assumptions: In this scenario, patient volumes are assumed to be the same as in the Business as Usual case (Scenario A); however, Medicare capital payment reductions are only 20 versus 25 percent, Medicare payments per discharge increase 3.0 percent annually versus an average of approximately 2.0 to 2.5 percent, salary increases are held to 4.0 percent versus 4.3 to 4.4, and the hospital achieves a 5.0 percent productivity improvement. ■ Pessimistic Financial Assumptions: Patient volumes are again the same as Scenario A, with Medicare capital payment reductions of 30 percent; salary inflation of 4.5 percent, and staffing levels increased by approximately 5 to 6 percent over Scenario A levels. 17 - Table 7 Ootinistic/Pessimistic Financial AssLWtions Project County Contribution (000s) Scenario Costs (000s) 1992 1996 Business as usual, with optimistic financial assumptions 88,788 5,676 10,015 Business as usual, with pessimistic financial assumptions 88,788 8,672 17,936 ■ Renovation/Current Facility Scenarios: In both versions of this model, the County invests $12 million to correct known facility code violations (as opposed to all known problems with the Hospital) and finances the project through debt obtained at an interest rate of 9.0 percent. The first of the two scenarios includes the same utilization estimates as Scenario A, with assumed volume effects of the new facility removed. The second reflects Scenario D utilization, again without the additional volumes which were included as a result of the new hospital. Table 8 Results of Additional Financial and Utilization Scenarios• No New Hosvital Project County Contribution (000s) Scenario Costs (000s) 1992 1996 Business as usual, remaining in the current facility 12,000 8,642 9,737 Aggressive utilization management, remaining in the current facility 12,000 8,382 8,843 D 1 V 18 - OTHER POTENTI& UTILIZATION SCENARIOS CONSIDERED In addition to the presented analyses, two additional scenarios were analyzed: 1) one t. three hospitals in Contra Costa County terminate their Medi-Cal contracts, and 2) a "Worst" Market and Financial Assumptions condition. The assumptions and results of these scenarios are discussed below. These represent events that are generally outside the range of projections based on historical events, but are included since in today's volatile health care environment they are not beyond the realm of possibility. A more intensive market analysis would have allowed for more consideration of the probability of these types of potential events. These two scenarios are included to suggest the range of possible impacts should developments like these occur. ■ Hospitals Terminating ParticiRation in Medi-Cal. Should one to three hospitals located in Contra Costa County terminate their Medi- cal contracts, Merrithew Medi-Cal volumes would likely increase significantly, generating demand to fill an estimated 2 to 11 beds. If a major hospital in the County were to withdraw from Medi-Cal participation, Merrithew's bed need could increase another 10 to 15 beds. These findings are based on a review of Merrithew's market shares in areas served by three hospitals who may, in the opinion of Health Services Department staff, terminate their Medi-Cal contracts. "Worst" Case Scenario. The basis for the financial modeling of this scenario is the pessimistic financial assumptions. In addition, we also adjusted utilization assumptions contained in Scenario A, the Business as Usual case as follows: -- Funding for the 8 bed adolescent psychiatric unit does not materialize, and the Hospital does not develop the service. 19 - -- Projected increases in Medi-Cal market shares do not occur, and the market share remains at the estimated 1989 level. •- Merrithew is not as successful in developing the geropsychiatr4_:, and AIDS units, with projected increases in volumes for these services reduced by one-half. -- The Hospital does not gain market share as a result of the new hospital. Should this combination of events occur, and if the Hospital were to have constructed 211 beds, the bed need resulting from Scenario A (the Business as Usual case) , the,County contribution would increase from the $13.8 million resulting from the "Business as Usual" scenario to approximately $19.5 million. It is possible that, at some time during or after the end of the projection period, certain events and/or initiatives could occur which would dramatically affect the roles and use of county hospitals. One example would be national health insurance, which could reduce Merrithew's role as "the provider of last resort" in the County. We have not attempted to model and/or quantify the effects of initiatives like this due to lack of certainty about their eventual characteristics. t APPENDIX ' t r - ♦4. APPENDIX: TABLE OF CONTENTS Exhibit 1: Graph of Merrithew Memorial Hospital discharges, Patient days, and average lengths of stay Exhibit 2: Graph of hospital based use rates (discbmrges per 1,000 persons) for Contra Costa County and California Exhibit 3: Summaries of utilization model assumptions and results for: • Scenario A - Business as Usual ■ Scenario B - Good Market ■ Scenario C - Bad Market . Scenario D - Business as Usual with Aggressive'Length of Stay Management :ummaries Worst :Case Utilization Scenario Exhibit 4: of financial model assumptions and results for: Scenario A - Business as Usual Utilization in Replacement Hospital Scenario B Good Market Utilization in Replacement Hospital ■ Scenario C - Bad Market Utilization in Replacement Hospital . ,Scenario D - Business as Usual with Aggressive Length of Stay Management Utilization in Replacement Hospital ■ Scenario A - Business as Usual Utilization in Replacement Hospital with Optimistic Financial Assumptions . rScenario A - Business as Usual Utilization in Replacement Hospital with Pessimistic Financial Assumptions . ' Scenario A - Business as Usual Utilization in Replacement Hospital, in Current Facility ■ ; Scenario D - Business as Usual with Aggressive Length of Stay Management Utilization in Replacement Hospital, in current facility ■ iWorst Case Utilization Scenario, with Pessimistic Financial Assumptions Exhibit 5: Detailed list of baseline financial assumptions a ' APPENDIX: EXHIBIT I w I, � Q1 rYm m WCIOacc� co W c m > N _ c � co Z )l- m a °0 Q Z N O d W p U a co W aw m m a iU U ¢ c cna _ CD Q cc _ C� C .. o � N N O 3A O C H U.)U LL to JW a N ¢ CC _ Q �— J UW cc 2 � a0 ccco CD CLCD Q I oZ o N N FQ- t o N c m N W _ co CD Z ¢ J W p a W N Q W c ' Ln m Q co W U Z Z U Q co N m u) v co a o In o a o i APPENDIX: EXHIBIT 2 D Q Q WCL `o t U. ct J LU VLU d U LU p Cf) Z � Z + � O � V . 0 Q W N Q V N m W a W = V U Z ui W Z i 3 o o �• Z a � Cl) a 0 � a U) 0 i V Q M 0 U) APPENDIX: EXHIBIT 3 .......,.•,.ar.:.u..aS..Cn. r .• r � R ; NO NO nn OV U1 •Or TONS .Nr� A � �to,;! V� • M N N N TQ • N p. 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M��rpp �N r • IVO M1f� �Mx1 POM SSI► MNO NO A•O _MA MM r N rr H1 MO me'- A .W r i O • N M M O J N 14 N • M J M V / r x ►� �I�f� YV NM P PSM HS'OA M^ NYx1O OP O .- AO N~ Or MA MM r .p —aN �h O r • • N M M 464 'N • N Y r�r 4 Mr 7 � O V x x x -O"+ P • rp NN d0 A 'MO �INM Vhf NOO 00 Y L ON MA PJ r •OM N P rM.0 • • &Mh _ • • N MM 'YN P;0:W; • N�f xx �t 1 M r WIN P•0O N �Pvfi OJ rO p a A�f r r M1 ON— N W;.O • • YN �` • • N YM NYN OOM r • r r rr'r NJ M r . f� • Vx1 HV K1O i7 YJO go I+1 �N.xO NO ic+ • rNM rPN • • ON P rY MM YN N •O OM1► VM r • N NV NYN ANO r- r r r O M •O NO NP HO V JNO �rVN P • .OY YY MM N .Opolo, INN • NMN • • NA r • • • N M N P Y V 1-0 0 O N N r • F t - J O Y H u � K i J W = W Z 01 F < IK► K S.0 dic 1 W / M H Ltl y1 7 /� U b M 2U / 7 U ►<<- W/1 C i_ U L / L O C H U L / qq� + L O qq W F1D U K ryy Y N � OY ► / UV MUS r i / Uua �+ Yra i SMV_C � T.r 31- OC t U L i S L�II 7-10.0 O L t i•+ O L V L L 7 WZ1L N C Z UIN 1 V II< IN< 2 2 �:)tN ii77 v�+ W 1U1 !R. L K YC �• r Oc �_f✓1 i tiO 9K0 6 6 CilAu • V i < = V t 6 Q • 1[� O -A 000 OM PpM N� My 000 ��O pp yy1� r I r M J ■ yA O 000 g P�AOVM rJ i M M^ V i M M O 00 OQ SO �A NMf i N1f1 AN SP r • NN M P V i O OM O.Q PM ~� �� �J � � ■ i r • p N • • • NN �� V • rM pM� I O M N �N Or Ob v N r P I • O � . . • . J^ N N r xp . • N V�O V J � • �v • N N N ' � •OO .OJ `qq N C < Y _ xxxx U p O V 00 �M W N P I . . . . . • . I I OA ppV Oyu �V i i ON;! P V ■DP . M n� r Z O C M r QQ . p xO =� P � . . . . . . . . .At�O JJ �y1• �V � ^ N D • �O I: P N Irl e n� r o v ux poll., bO 'M • J • +Nt f1 I M r O J ND P i 00 J WN � N y1 r • N O O P r M Pon, . M A N OIej On N.00 OM pn I V N I VM 1�`� NO P ^ M M x ■ ; A Nit 00 AA • • A M PM O Ifs • r r • O P � NN • ~ N r Y J_ • N► NI . W L L Y � Y t �5 � C Y Y V • Y tr �.Y NI W U _U rY ' Y �+ Uu N {7(� U V y7U , U 7U M S 1 L • L r w L O•L > • O O•.O. + (U(��e O O W LL Ll Q L L LZ 0 $< s < o APPENDIX: EXHIBIT 4 • • N OOSNtPO OAN O4N M Mfg M y • app rPai `O.O.x-P M O� � v P .fNO NVV�MM N y� .f �OOV a NP N Y • . O` NMVMN NMV P M+VV�� O � y �'� � SOP N •ON ^a u • • xx xx � M y • N N��O�yp� �p bu NXb Nxbp�C 9lLp7 N K. 1A � p .OAA A NCD .pip y P •O NCD N�V�MM N MNVMN NMA N AOA N PM M N fV Mgt yN1 � Ntl r MON . V N SON v M N � � v 1OA�IMN�S•O ~+MV Cx1�x MOx�(• ��vNN.f MP1 N �AAO .I.O M0 M M MIpA►, M�yN - ��+� O N P xN ppyyo� • N ~AA r fVN r N • • M v M N • v • �kK>k>K� WQMpp`. O^ NOOV N b V N.O COy �ey�P O P- V� �•O Nr M'M M1 N OGGGG PP CC OO O AVS M %r N N O ; ^N fy NNMMN NMA app • �f N M•O� r �N N q K . M v v tl V Q . • O �tx x p/� KK K k K M V N A N •.~• ONpS A NMOON� AA M�r1 fly, NVMPMI MI �O VPV •.. • V VP NV � NNV VN NMN • • M+V N V VPv NGV N O N qq • � M ,OO v Nv Y J 7 �_O • O. O . P • AAV �•O LeA!KKK OO+ xKon M MVONm 09 MIMPMM Mw N N Nv A N m • MVCO NV N�V�fN NMN • fV �f •O NO� ON N A N m • M S V • x J � • v v N pp<_CC qqq 1iSiyOm• • pP MP.p M1�.p`�AyC' V Cy pn 00 MNOp N NM� O P N—VVN YN M NN ey N vN �+u L Op Mx1 NNV�O aO . �A A OM ./ N y� o V O u ^MM M V V N N N N N i m W • xx xx��(( xx �.pp 1 O O•N+_ CVNOO�N P . -6OM . oso O' N N y • r • via MMMNV V O OL N NIN, a NAS COV 10, v •••ppp M V V v V y N • O ! VO.Ap ��PmM . Nr•� • . N • ^ge NM ^ OM OP u �P • ,MONO RMM�N•O O PMO O f�MN1O P .°D. .pr N r A Yr v VNNi N M y >K>K K K>K .pp oAo.f+ MCDMMN P NW%_� Oy� 1�OPPM ANMMVN NNN �P • • • • • • • CO PO N V V N A Y • NV N �O� Vv 11^p N M N O �� M V V O V N N V • M M v Y O to Is AL 3- m g wg� �OOY in ►max O m N N `= m Y �� p �C L pCM 6i C L C•r E 0 � < Y7 u CI�q � t7 '07 y7 Y MO IOAC 111& .�•.•� i~ b EEa �1 � �Vr+uSY Ssc �M Ym WLY u . —5 4.0 m C[ u L W J O+ LILL. 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SAA O NN O�K • • � N r • * M r YR • v v Y t a �QrQ(('' yy�Q�Qtt xQ�j,�Q! y► p �p pMAp ' aP ' N O PO OFw•D MP1 ANA A wF%.p yA� Y ; MM •ONMI'!MM 0=�0 M V•Q N M O MpN NV' •� it►N.tMN P4'i fN M�f�► ^ "�M"+ P M • N V v Y • • pp�. ppx'� �pt xxpQ w w Q+ WA +OOVtxn0 V .1AM0 G�NMM q W b!•1M0:M14 It1•ftylr O u� �vpp N r i �' • MN1-fN N.t f•• ^ - MNvf.INM� N N•Q� ' M N a ++ • + N v V Y � r • J + • Y + "' j pYi•O Vif R •ON O O� lti0 ' •O QOO N v N 6 L • y^ O v V' its ifs •,iT N = i P^ • RA N�MOMIM 1f1N W% N N p0 N M•t A Y YN.M.f100 V • • i p pV .xtN .Q� .t K NM N O �r+r Y+m • Q+ . �•O N � � .f �N if•�O O O O O ��.f It• M� V7 N Z + P RR •OMMPMM IA PNr N MMMfff � N _.� i N�f R N+t a^ ' iR•>••t•t N ��t NY W L • . 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NOO NOOO NAM AA Ni�pp O N •"P • rO�N VYVOMM N •O Vr0 N N W : NMOL NV ffVV .r MNY MN P;b; • ^ • V N ~ N N � • 9"—.r bm • N v v N f • _ AMpA ^ Nqq..t� r0 r A NrMNMM N NNYYN rig •p lOn w Or : • r.A � N V O N�� � N O N V • Y M r 7 • • w v y r 49 ft 0,' Cpsxxx�e be be _ pxxp ga�ppe px�pe puo�p� A �ny1 A Z f : $. : OWN ^MO VN ONNMO OPO NON N Arpn o N N NPV .OMMppMM N PPP Y M M NV •O N = N V N ^ N Y Y N N M V (1 CfV V Nv An P M V1 40 N <C r +V f N • _ _ xx be be m� Qppp p�pO.p NN �pNN V 8bO�8 ONS �oN M A N "� � ^ P1�•O �O MMPMM V NNM O N P�� N N M Y 3 G O r • N AM t•vv Y M N�O N N A Irl r� > • v v■ O: b • • x�e � W. 60 2400 . •OV ���vf►M M �Otxxx Cx apptt CC 1y!�• r. �Y�f yy�� ONY�O O� • r0 PvN ;N! NANMPMM N r80 Oq N c< E^ : NVA NV ^ NNW)Y In NY NV A M M N • NM �+ • M'V • x NN v M + Z b W • • NNGO�N • OIN • � • O V ^ OV N N Y • P r P O : NV.p wl cu r NAS40 • • 4 f O Or Y r s M"v N YV v v■" �• xxx.�exx $ �exx o .. ,. 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LLQ ZO r • L • O K <JLL�+ • = • YLN•�L � Y 4 NS O+ate••+ b VL + _W 1•� X Cp U •� O O c�i Cp L yX1y W Y J•+ {a�U« U d 0 r ��9 d►. YIZ di.l..dt O �1 t7 d•� dOi rL1 {.7=O S�•►d �2 O W 2 7T a d x *ME p eW[ x"xxxxx xse x�e x _ I NdN MVrdVO P 5040 0 8N� A MPN d y��A IAr� M P I-Al NinV�MM d OON .9 AP N � aN A PP A N eyIRMVMN NM1d d • • OV M fV •r f-id MAS ^ Ifs P M I UN I M r N r V M • 1 x x�e I C`•O�• I��Of�14 H V�q :f 1NNPO OAd V ��n�d OA•n vNVPMn •O • AVN NV � N NNVMN NM•O V •an on I I N v V N � � l Qy �pO be �` • A•Y►�E NVOx1 G ppNO _ QP VV1M N M Nol 40yP PvAA Nv NN p N I MrN ffVV �t N N%A N P N M H M v N •_ sex�s((x�exx �e p p pM-• M M vNP1�N� r oNPg gr�+ A dV0• N v.p N H �` ..pp yy O• ...ppp C Q O P.MtM N P•O P n O �VM^MM ' NNVMN V�Md r fV V N • N v v q M d I -' • N I AOA xxxbe 34 14 xppKKK x .•. i+ . •O N1�1O47 Ver V OONMO OPm P AM P N r pp p pP yp� �p v n O • P . 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MOA NV POM N I �—^ I • N I A ryryNM N OM Cl N 1/.n PW M^Nd O O AM� P v v i1 Y N PMO ^p V V M Y P V N N Y M v j' A V+ x X X x X�t Pn MOMMIAP NOS • 1 I V Ao GP O� _N II • Pit" A•RMMUN V • I I g V I I I V Q V V P N A N If N Al N O N . O O V Y N NAV N v N I • II r CC _ O m 4• < • L� • • N M rE� O N Y V ya 40 g CCC g 41 Y u {% N 1 E N H � q 7 v C O YG Y 066 � !• BoQO • V � � � L � L �` � + r C 4 O N� y N M Y •Z N •� YC V r a YO S H [ V M L Y _r N _ < • • Y r r N • < L 2 VY 6 N • Cr �• O. 7 0 •- W r U NN N V 7 Y y L � ,•Fg WVrNY Y_LY• L. N U 3• _ Y < Q ri Np 4A 6 4L v W • EL. +C DC> v 4. Y L O •+ x •V Y • Y i W J •+ r M L U L r f�� > WCIU.r < >r _>�, 1<i a. L Tjc y 4 = NN� LQL ZYIK 4 ••• Na • @+ O YLt N N L •r r d N O W 4 L O L r _ owl 0. 4 N 0 L W L z Y 6 W Z L O �/ Op t( O 4 V0- aZZ�VG< O N Ver. Gm VZ{,�iO SZ•►CL NZ W 2 Z • a a I i e<[ p of I / I 1 •pO. 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P • NPV N�MNMM N O 00•a P +n�t a M 1R r J V Iff IPf M J • MMA i r !V V v N»„ r ~ M q MrV « v w r — a ✓ }��t �Qt yp� }q�. ,p v y� .m.� • • rpdr•O V%WN f►•O fAN V OfANMO QOO tly(�i NAM yQM� •4 p+ r O�A•O •OMM'MM1Y;1 V�'•O O NM 1 M M N V N ttf r V V A O V A �,•,M tl M N h r V 6n W-4 w v■ x 4 Y • to K Y N vexx gyp( p xQ �1 p. ZN L �S ��tlry'f�yfA0�a ftlnkOVM N OMrVMO O� a P�'O wMt O.O h M ,C Q• wP • h.l�J hNMPMM •Nr • b NV A M M N ✓` N V A N V r ^ N N tl V N ^V r N M r N N .1 M V • wt M1 fA r « It ✓ • � N v v N 9► W • I f l/nOO�N P h N hlO O J ^ OV N N OOH • v O n • •�'� • � �M N .� a N n cp, rV'O dtlMdVV WN 1. OV N • . M M N N • • !Y! tl P V « x W s • N V�,! 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M OO1A0I OPO M Nf0 M A i M • M N N yyW�r • +ifNP NV N Nr inty NM OMYN .p i b • Mr.f l f � M M•O.O v rN M « • Y • s t s • � : w�$� ,o'rw�M°•"p"MM v Z5�rn2525 75a� o .be I Nirol Q Nn • r • M1 V 0 N,i.•t tY fy N N ft N N M�T fy wM • • A V NN N N r • f M r V • r 76 f + � v y i J W • • }. • • x xx xx y�x p u ♦ pp ' �QN uKfO hf.xpN N 000 bA� w m0,P • P a OAaMp fO�M MOMM V NN PN P K•MP 8 S%r N Y • r • MVA N',IV N Nr+I NN IMV O N.J" M i • • MrVif 10 NN ■ 1.0 v y■ • • st s�!st axt r�Qf�l�F. mit yQQt •• p. w ,ABV N MMM N �.W!v! S M14O N CV i ♦ r ♦ M P N N O MMM111 V ■ ej r MrV 'rVNN • V� y NN to • t N V y■ SK yel.p+ • pp • yI�� [•IWO xxQp gy�pp{{ yp�ip app yp�. �p yp► s3 ✓P : AAr A,N MPM ~ QNVO 00 • W ONwOt A OM t•S r Wcw %44•;l NN NV ■ _r i „Ai N�� r r N M r N +ip Irl • � N N r N M t y y■ yI • xx i • i . a�r (yNbZi�N +�pp ' hF.N O O qNM O^ O i P P • VOM • rr • r O ~ r : rV•O pMOV r MN r P N r mm V N O N A.r ■D.f � O P � V f0 1ri ' • • t M M V V v y« • • r Z NxKKi< 14 f A : MvA�pp .pr aDM O • �.,� t 1 N ♦ r�yy'NMy N OM ppp~p. 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Recommendations V.1 Appendix A - Patient Day Projections Appendix B - Baseline Financial Projections Appendix C - New Hospital Financial Projections .i TABLE OF EX MrrS Exhibit 1 Historic Patient Days 11.3 2 Patient Days by Service II.4 3 Population Trends II.5 4 Population Age Mix II.6 5 Population Growth Rates II.7 6 Patient Day Use Rates II.8 7 Service Area Map II.10 8 Medi-Cal Days II.12 9 Total Patient Days 11.13 10 Medicare Patient Days II.15 11 Discharges of Solano Residents II.18 12 Projected Utilization Options II.29 13 Projected Patient Days II.30 14 Projected Total Patient Days II.31 15 Projected Medicare Patient Days II.32 16 Projected Medi-Cal Days II.33 17 Site Development Analysis III.90 18 Existing Site Plan III.93 Recommended Site Plan III.94 TABLE OF IIXH][BITS (CONT) Exhibit 19 Recommended First Floor Plan III.101 Recommended Second Floor Plan III.102 Recommended Third Floor Plan III.103 Recommended Fourth Floor Plan III.104 Recommended Fifth Floor Pian III.105 Recommended Sixth Floor Plan III.106 20 Assumed Project Development Schedule III.110 21 Option I - Base Case Financial Projections IV.3 22 Option II - New Hospital - Financial Projections IV A 23 Comparison of Option I and Option II IV.5 I. BACKGROUND ANIS APPROACH i i. i BACKGROUND AND APPROACH i TABLE OF CONTENTS i I. BACKGROUND AND APPROACH Ll Background; I:1 G Approach I' I.3 i' i i i I � I f. i I i i I I I i is f j i Ii BACKGROUND AND APPROACH Arthur Young was engaged by the Health Services Department of Contra Costa County (the County) and Merrithew Memorial Hospital (the Hospital) to provide strategic, architectural and financial planning assistance in order to determine the feasibility of constructing a replacement to the County Hospital. In this section of our report we discuss the background of the project and the approach we utilized to perform the study. BACKGROUND i Merrithew Memorial Hospital is owned and operated by Contra Costa County. It is a full-service inpatient hospital with 191 beds, and also provides mental health, geriatric, and outpatient services. The Hospital campus currently contains a number of separate component facilities,as well as a main hospital building complex composed of several wings. The wings are located on different levels of a hillside, and are connected by a roof structure and a partially enclosed corridor. The oldest portions of the hospital complex date back to 1914, and the major portions of the main hospital were constructed in the 19409 and 1950s. The buildings and systems are almost all out of date and at the end of or beyond their projected useful lives. They are still in service through the continued maintenance work of the County and General Services Department. The facilities generally do not meet the standards of current health, safety, building and engineering codes. In short, the Hospital has been characterized by both supporters and detractors as antiquated and beyond repair. In fact, subsequent to the completion of the data collection phase of this project, State of California licensing authorities conducted an inspection of the Hospital and notified the Health Services Department of a number of violations which will need to be corrected. Preliminary estimates of the cost of the required corrections to the existing hospital are approximately $16 million. The cost of these modifications has not been incorporated into this study. i 'i i �' L1 i In Contra Costa County, the burden of uncompensated care borne by Merrithew Memorial Hospital is nearly-60% of,total:.uncompensated,,charges-inthe:-County. In addition, the population served by the Hospital brings a variety of health problems associated with marginal economic status, and the inefficient physical facilities have presented additional challenges to County management. The Board of Supervisors approved, in concept, the recommendation of the Health Services Director to replace the facility with a modem facility, but requested verification of the feasibility of such a replacement project. The County then engaged Arthur Young to determine the feasibility of constructing a replacement to the Hospital. Feasibility was to be evaluated in terms,of availability of funding, alternative funding sources and impact on the County's General fund contribution to the Health Services Department. In addition, Arthur Young was to project service volumes, recommend optimal program configuration and size, estimate operational and staffing costs, develop a preliminary functional and space program, and estimate project costs. In addition, the County requested a special focus on evaluation of additional programs to provide the full continuum of care for geriatric patients, perhaps under the umbrella of a Geriatrics Institute. To guide the planning process, a series of working assumptions were prepared by the County. They are: • The replacement Hospital will be located-inMartinez on the present campus • The Hospital will continue to be the majorprovider of services-to,low. -income residents of Contra Costa County • The Hospital will be one element in a continuum of services for,the:elderly, forming a Geriatric Institute • The emphasis on outpatient services throughout the County will continue • The County will continue to provide a full spectrum of mental health services, including acute hospitalization 1.2 • The County cannot afford a significant increase in General Fund subvention of Health Services. Net costs of operation and debt service must be minimized and external funding obtained if necessary • Wherever possible,and economically justifiable, existing structures on the Hospital campus will be renovated if necessary, and used for outpatient services and support=staff. i APPROACH We structured our approach to this project to address three phases of analysis with specific attention being given to the interrelationships among the phases. The first phase of analysis was a data gathering effort to assemble all relevant information,including previous studies, on the historic, current and future utilization of each of the components of the Hospital. This data was combined with a profile of the Hospital's external environment and an assessment of future trends likely to influence 'the Hospital, to produce,`a Hospital resource assessment and to propose strategic alternatives. Scenarios and final planning assumptions to serve as the basis for following phases were presented to the Steering Committee for review and approval, and presented to the Project Oversight Committee. The findings and recommendations for this .phase are presented in Section II - Strategic Planning. The second phase of analysis was to utilize the approved scenarios and planning assumptions developed in the first phase, and the programmatic changes selected as preferred alternatives for the future of the Hospital and conduct departmental interviews to determine;appropriate space utilization. Facility alternatives were identified and submitted to the Steering Committee for approval, and presented to the Project Oversight Committee. The findings and recommendations for this phase are presented in Section III -Architectural Planning. I l 1 I I.3 The final phase of analysis was to assess the current financial situation of the Hospital and project future net County costs to serve as the basis for comparison to the financial outcomes from the preferred alternative identified in the previous two phases of analysis. We prepared projections of financial results for the selected:program mix, and a reasonable number of facility and financing assumptions,and performed sensitivity analyses of critical variables. Finally,we identified alternative financing mechanisms, which might serve as sources of capital. The financial feasibility analysis was reviewed with the Steering Committee for selection and approval of the preferred scenario. Our findings and recommendations for this:phase are presented in Section IV- Financial Planning. While this project was estimated to be completed in approximately one year, several factors contributed to delays in all three phases of the project. For,instance, market changes in the County during the last half of the fiscal year ended June 30, 1988 contributed to an occupancy rate increase at the Hospital which was higher than the original estimates, requiring significant adjustments to the patient day projections. Completion of the project was then put on hold while other replacement options were discussed, e.g.,joint venturing or purchase of another facility. In this final report we have integrated the preferred programmatic alternatives, facility plans and financial analysis of the:proposed scenario. This report encompasses strategic alternatives, the optimal facility plan solution, and the financial consequences of these plans, and can serve as the.basis for program direction, capital improvement and site development to guide the future development of the Hospital. I.4 ' r! II. STRATEGIC PLANNING . 4 r 4 i t }} 7 I i ..j STRATEGIC PLANNING TABLE OF CONTENTS II. STRATEGIC PLANNING IL 1 County Needs Assessment iL l Contra Costa County's Role II.17 Access to Care for Medi-Cal Patients II.19 Geriatric Program II.19 Obstetrics/Women's Health Program II.21 i Responding to Unmet Needs - Aids II.23 r t Enhanced Medical Staff Practice Opportunities II.25 j Scenarios for Merrithew Memorial Hospital II.28 a H. STRATEGIC PLANNING The objective of this project was to determine the feasibility of a replacement county hospital by selecting a reasonable course of action and testing its feasibility. The selected course of action was to meet the following objectives: • The County provides services for which a demonstrable need exists * The selected course of action is reasonably affordable • The programs capitalize on the County's existing strengths • Maximum use is made of private sector resources • The future health care needs of the elderly poor and medically underserved are met. The Strategic Planning phase of the project sought to address a number of key questions: 'What are the health needs of the area? * What are the health resources of the area? • What unmet needs can be anticipated? • What is the most appropriate role for the County in meeting those needs? • How can the County optimize financial results and private physician support? * What scope and configuration of services should the County provide in the Hospital and Geriatrics Program? COUNTY NEEDS ASSESSMENT _1 To determine the health care needs and resources of the area, and identify anticipated unmet needs, we reviewed: * Population trends and projections • Housing development profiles • Historic rates of health care resource usage IL 1. • Availability of health care resources • Geographic and economic access • 'Specialized regional needs As this project began in early fiscal year 1987, we used the most current data to begin our program analysis which was fiscal year ending June 30, 1986 and year to date fiscal year ending June 30, 1987. As the study progressed we incorporated the most current data as it'became available. As of the date of this report, historical data used was fiscal years ending June 30, 1986, 1987 and 8 months annualized 1988. Historical :patient days and patient days by service are illustrated in Exhibits 1 and 2 on the following pages. Our review resulted in a number of tables which are presented in Appendix A. They include age and economic.specific population projections, future health care utilization rates, and patterns in utilization of private and public resources and projected patient days for the base case and the program alternative scenarios. Our findings included: • Rapid populatiorrigrowth, especially in the..-.65t. --,,,and75-and-over:-age;groups, both nationwide and within Contra Costa County (see Exhibits 3, 4,and 5) • Access dto-private pliysiciains for Medi-.Cal-and other low-income-populations is-deEq n g as more and more physicians are refusing to see any Medi-Cal or non-cash patients, forcing them to turn to the County and to other public sources of medical care. MMH has the single largest market share of Medi- Cal patients in the immediate service area as well as in the County as a whole • Access to-nursing home'>services`for iVfedi-Cal .and other low-income populations is also declining-within Contra Costa County • Use-rate trends for acute.-care are stabilizing, nationally and within Contra Costa County, after declines in earlier years (see Exhibit 6) • Demand for services to populations with chronrc:'conditions, e.g., elderly and AIDS patients, is increasing in Contra Costa County • Total County-wide demand for acute care patient days excluding Kaiser patients,is projected to increase from 300;000 to 380;000 from 19a&to 1994. 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W, 14 W,"*'!,4 • .:r O W*♦ is ri:{;i{:=i:^i: 7:i'' ::-:ii}::r: w #r, r,�r r r�r+i,,qp 1p f00 An analysis of patient admissions by zip code of patient residence for the calendar years 1984, 1985 and 1986 was the basis for defining MMH's primary and secondary service areas. The primary seFvice areaC fai 'theHospital,consists<pofart�nez and Pittsburg. The primary service area accounted for 3rcent of total admissions in 1985. The three secondary service areas of the Hospital include: • Concord - Concord and Walnut Creek • Richmond - Richmond, San Pablo and Rodeo • Antioch - Antioch, Brentwood and Oakley In 1985, the Concord, Richmond and Antioch secondary service areas accounted for = 23.2, 21.7 and 10.7 percent of total admissions, respectively. A map of MMH's service area is located on the following page. Following the service area map, we present a summary of the competitive component of the study. _y t II.9 J s V W '.'Ji Ji ii}il't 1 '• F 'TS'S F*1 t�l�ti 7 1 { ilil. .'1`! t i i I ! 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Illllllit } � � } i I i # i I l ii t i y # Y N r 96 W tom+ IT• 10 i , is COMPETITIVE ASSESSMENT QVVgr W6es TmRliotions In the immediate service area as well While Medi-Cal patients have not as in the total County, MMH has the traditionally been considered single largest market share of Medi- "desirable", they represent real Cal patients. (See Exhibit 8.) revenue to MMH, especially when considered as incremental to the "basic", i.e. indigent, caseload. This strong base is an asset to protect and exploit. However, MMH is not alone in considering these patients incremental, and can expect increased competition for them. MMH's overall market share of 10% Although much of MMH's market of County patient days in 1985 makes presence results from its role as it the third largest provider in the provider of"last resort", its size and County, behind Mt. Diablo and John rank as third of 12 hospitals (treating Muir. (See Exhibit 9.) each Kaiser facility discretely) makes it a substantial presence in the health care delivery system. This is a significant advantage in protecting MMH's basic existence and as a starting point for market strategies. MMH almost doubled its market Despite physical plant problems, share of private patients between 1984 MMH has managed to attract new and 1986. Although the absolute private insurance patients, especially number of cases is still very small, from the Richmond area. This may the increase in the number of cases reflect continued usage by formerly in private insurance almost equaled indigent or Medi-Cal patients who the total decline in Medicare cases. have gained employment as the This gain is especially notable when economy has improved. It may compared to the declines experienced indicate unique competencies at by other hospitals in the County. MMH. k _! MMH substantially increased its While other hospitals' increases in number of"Other" payor cases, a "Other" were at the expense of private category which includes HMO and pay (presumably as insurance self pay. However, its relative market patients joined HMOs), MMH gained share declined. in both categories as private patients and Health Plan cases increased along with growing indigent demand. II.11 I e • ►♦o ♦e ♦ o♦ /♦o ♦e♦ ♦ ♦e eo ►♦ ee♦ 0 } ♦ee ............................................ ♦ 1 e 00 ♦♦e -; ► ee♦ ko . .: , .4—MM-4-4♦♦♦♦ i <•.; +rS�.v, :ccs:,' ♦♦♦♦♦ <c-�2Rt�?2 L F�'+:Fti.�'L4?;�L. �a+"� ;C= ♦♦♦♦♦♦♦♦♦� ..Q_�;�:;:+��i<"i�.���:`;.Oy+.xa?fi`"?�}':„-.,-.ice ar;4 NW-W—r- .x�•. ♦♦♦ ;;�'.l.i_:;{Yi?\�'4. yvi.ti:.+C:Yry:::::! .v.<i-�;::>?•:'::iiv oe♦ - ♦ �e♦♦• '.�:+iii�.,;.,,.:>:.!y:;%-.:�;.:::-;:-;::.;;.:..i;;:: �i; ::>;::�i�::�:<_: dee♦ - ..: ......_:. . .... ♦♦♦����:::=: :?iii"i%'iii;:is�;:':?::;'::>?:`isi=ii:��i">�i�:�<'s?E�i� :::?i;3:f< • ♦♦♦♦♦♦� �e♦e . : ♦e♦ ee♦ ( '•;'{.;;'''{'} ,'tL::{,Y"'"'`'' 4••4' {;tit•;;};;:;;;':;}''�: :•'i�yL Citi• f h•'.••�,,:''� ac ON _ HE-4•I f•'�%�fi :ttrt L Y'• 't � � %'•'Lyf•.•` � Ra {''• �• �t L fi'r's;.,.•}•, r,,, ['1 .k'i :•:L'.}{f:.•11e:" •:lf{y r t •t yy�yy L'';:•;�};;; •r {tt'vY tv�•y4{{�;�t,;f' rf v�}vrY..;• yy�� ::h.:. �5::••`:}ft`Y.t�f,.?:•f;'�;.{�{;'r`t;+r,"•.... r r Yvi.}*'•r•r.•. cc I cc t4{hh 4;;S ;,'SY �bti ti;y ':Y:$'.L,.',�•:`. Q Q ;..4;Yi h J,:t p t•M{''•1i y4},r r{6•:a;}b'{.,r t:•:y4•. f:;:,ti}tir::{`r.:}:�':•,'�;.;}'r:L'S:•"•......:{•Y•f$::•••:r:•:{:Y:L•rv.;•}'r;f:Y:} �/r�) :;:;:;:'?r,;;?°f:}fr, :{ ,•v wN•.,..•.;L,•{'':tiff''•'•'{•':{•:•:{;:•: {r,Y;:ti{;•+Ly'•.y4,h;.tfy:Srtip{t,'t'�:t'L":4;r{•'f•:�4'`•'''{{•r'{•:•:•:•;:q;•: O •'rr� �{.;:;.•"4 .;ti;{}x{`r,';.$Lt.t}'t rf t• ��,' 4�.Lv.•.'r:• q.r :$,tit{•�:,"t'yt'tis,�:S {:'w tvyh`?r':}` t?i%'•::;°•:ti%:$;: 1lS ,'` 't';y,t,�:t';l ti';,}, LS'''•.;�.• y: S{L''iLp}.5;;�y;,• CID � xoo Ln •`}fi:`f•:��t�}�L �'�.y`r:�% tt'v'•'t%•} t �,}r'•$�w,'}}rti�t v:•:•`•.;'•`ti•vf.?r:; -XI • 4};•:;:v: cis cc Lfiog'r ;: ��y {{, 7},vr :%;ti� }yr:•}.vtr{y, tyt%:ti:;.;+ }{$$C?:}S CM r 1 ,.;;.;f•: {+,tt`` .:%}pj.;'v L;»a::•{a:h•:yr%r%r''+%r%i+::^:{r:,.{;%}:%::::%: tl� ,;.• S1i`• L'• \S Ly{}4, tom{} `'•.4;,t•:t•1. •� U U Z aUl) o a o $ c"i. tV N r T O co 11.13 COMPETI'.LjIVE ASSESSMENT Threats Tm;Rlications Overall use rates (admissions per MMH is competing with other area thousand population) in the service hospitals for a shrinking pool of area, County and all major planning patients. Shrinkage is most extreme zones declined between 1984 and 1986. in the area where MMH was traditionally strongest, Medi-Cal. Therefore, MMH potentially suffers more from declines than other hospitals, if all other factors stay equal. Total use rates for the service area Short term declines in Medicare declined 2% while rates for the admissions are partially attributable County decreased 5%. This was to DRG and other cost containment consistent across all planning zones pressure. Declines should stabilize except Richmond, which increased as use rates flatten out and 2%. population grows. (See Exhibit 10.) Medi-Cal declines may be more lasting as program and access restrictions suppress demand. However, this may also lead to future increases in acuity and resulting demand. Problems with access to physicians may result in redistribution of demand between providers. Private pay shifts to HMC? and self- pay are likely to continue as insurance premiums begin to accelerate again, corporations continue and accelerate restructuring in the face of economic uncertainty, and employment shifts to service industries which traditionally have poor benefits. MMH market share changes between Due to market share declines, MMH 1984 and 1986 reflect declines in many lost even more cases than those key markets, resulting in declining attributable to the overall shrinkage admissions beyond that resulting of the health care market between from declines in community use 1984 and 1986. In order to maintain a rates. constant census level (independent of population growth) MMH would have to increase its market share each year in the face of declining use rates. II.14 '•L�}L;};.'}•h }ti::Lys ,.•M. ,rh;•' •C•>'•'�';�}:}•L•' :. L h L.i':':'..•''''1 L'L .y .,ti�LLi:S YM�.ti•.�L{}L{•, :L. L L1'•.LY.}LO}}:�•}: tiyYL{L,an �rLS�r��{'�'•y}:•; L`Se?Q'r\Lv{•}r'•i�L:'�hL Lir Lti}Lh`r�:{:•::::: ;•.{.. }L,:}� L}.;•'L{LL L}...... •'y Y.L. };:'^'•.: :�'�:•:�: k Yh•:'•�.•.}{:�:::} L}• ray}yL•yL r�:�'r: CD •ti} , .,.}`L LLL•V'LV,'}:• ' h hy'Y L:•r:r. - (� � ::{{;• { L;'•Ltti•���ti{fititi}:ti's{. L, y;LfL'YtiZ'��{;'{v':' � a 1--1 � :�• L L-•fir• LLL'•}• L�.�'�., �`.{tiL,hLL' 'LLY• L;Y ::LL}•r. �L 'fiS• LL .Y44LY.1ti L .r ��'ti�•h;; Q) CCJ :.L L 4�'L'{Y�:L'y�4:y}:M`'.•} �'titi;fL{\'; r a 'xi .• ' :8�.','Lh:.YLL{{�Kr LY•}•L '} •{r{•'r;i;r}: W 0 �� }S!��},,�L,L r {k 4{'L . �L :•.L, Y�.•{:'. ��,�'•_•�..•�y 'v} L 1• •.•.L{•LL•L.• :C•:L} }LLL}{•:•.•: Co ''•SviLC\LtiL <, ., 'ri�L,{i�<�{'�r,.•'rp.,L{}.•yr� '{Lr�''LCL}Y:;:�: .- ,'''.';:'.',•••LL,.• `•^`•xr�'Tr:}��'•rL{4S{r •L,L PELF•'•••.,. :: :::•...L•...•.•.•.•..•.{{{....:.L•••r �. r4 rr L L•.}, L L� r• L, LLr�� }y{:�.Ly'�.:v:�LtiL":•• tiri�:}'::::: �:ti{i:r}L:•:yL•{JLC•}t{$:{•;;ti{v:L}{:{L{}L'•}\{'��}�rv.'.�L:,LL,'`,,. �..r V }r •.C :y}L,.:v ;.;$.kL}y\yy '. •LLL{Ly\ •• O yr K.v.L,L.{Cti••�:, ...:.L.}•..<+{tiy�:LLtiL'ti•.•. r7;;L{C?. C ti{r•L$r};v'h`'; ;.;.ti';y;::�{ •}-.oh`ti :�}{tiC:ti::; El Ni iLO � '.•'•}}ti::L:LL:L�:titi:C�•:•:•}L{},w,',�;•}$<;:,Cy,;:;��::��:�':;�44�¢{}ti}�: C .......;.ti'.:.{.....:;}{:Y:{y'; :;.;LL�.}J:,{;.}��;:�V•:L�{;:L{�.\V}:},L'; X. _N .'.L .. ..yC.0 ti�ti{fi'ti$::ri•:•,{:•v�:Cti;'r�ititiS'C:'•r.LY:��.. .r:.•'•;; •� '} •C' •'L:�C;'LC:;.{LL�LL{;LL•'�'�'L'}:'L;\,'h{C'LhL}LM;':'C::�`:;::.;..;. r Y a`L`tiLz x�. J C•hb7{ Lfi.,•;}.; Y 0 'i'}:y`L' \, k{\tiff•:• (,� 4••L: . •L h}L LLL�ti' '► /y� }`Chh�hµ;};.}'}'',ti L ••h• ��, LGL'•; Vr• �/_� •L{::•}'L{L •.h':•}:LL:'}.Y.':LL.y':'.•',S;V::•..���'L L;;•,k•{•}}}}}'•y:•• V N_ a Q _ U S g g Z IV N O m (0 IV N II.15 K j COMPETITIVE ASSESSMENT T TmWications Brookside has increased Medi-Cal Brookside is targeting the same market share throughout the service populations where MMH has pockets area and the County between 1984 of strength and strategic and 1986 by 24%. They have also opportunities. It is also located in a accomplished minor increases in market area of importance to MMH, Medicare. However, they lost market and one which is particularly share in private pay and "Other" vulnerable due to geographic access categories. Overall, their market problems. Therefore, Brookside is a share was flat (as was MMH's). direct competitor to MMH. Alameda County hospitals have The competitors in the Oakland area significantly increased market share are also seeking new sources of in several important areas, most patients which adds to the notably in Medicare cases. While competitive pressures in MMH's many hospitals participated in this service area. outmigration, Merritt was the only single facility which had substantial gains. Other hospitals exhibiting specific Doctors' of Pinole, while perceived as strength in the market between 1984 a "carriage trade" hospital with less and 1986 included Doctors' of Pinole competitive implications for MMH, which increased Medicare, private still has important influence on the pay and "Other"; and Delta Memorial Richmond area. Richmond is a with strong gains in "Other" and critical market to MMH. smaller increases in Medi-Cal. Following these hospitals in The increasing presence of Delta in increases were Los Medanos in both Medi-Cal threatens another MMH's service area and the County, important patient source for MMH. and John Muir in MMH's service However, it also implies heightened area only. competitive intensity between Delta and Los Medanos, a situation which could create opportunities for MMM. II.16 CONTRA COSTA COUNTY'S ROLE Overall industry trends across California and the U.S. are resulting in increased reliance on public hospitals for service to a growing uninsured and underinsured population. Merrithew Memorial Hospital and the County clinics already serve in a number of roles: • Major family practice teaching program • Medi-Cal provider • Sole provider of high-acuity psychiatric services ' Unique geriatric clinic and medical/psychiatric program • Major local provider for Martinez area • Provider for meeting Section 17000 mandates • Regional provider for Solano patients seeking physician access. (See exhibit 11) We recommend that the County's most appropriate future role include the following components. The County should: • Continue meeting the growing needs of Medi-Cal and other economic groups for physician and acute medical services • Expand and enhance services to geriatric populations in specialized areas, beginning with the existing strong medical/psychiatric program • Use the County's strong presence in the obstetrics market to expand and enhance the continuum of services to women and their families • Respond to unmet community needs which the private health system cannot or will not provide for, such as AIDS JEnhance physician practice and clinics to compensate for declining private sector availability while also supporting the County Health Plan • In conjunction with the above programmatic strategies, seek appropriate regional cooperative opportunities to use Merrithew Memorial Hospital resources to meet health care needs. The followingpages further describe the objectives and development P g � e opment strategies for the t recommended program alternatives. II.17 ►-+-4W . +moi . ;:: : ......:: ` ::::`:` � VA,WA .........................: • +++ .+.�. ; ACCESS TO CARE FOR MEDI-CAL AND OTHERS The medical staff of Merrithew Memorial Hospital will continue to meet the growing need for primary and secondary care in population segments experiencing decreasing access to private sector care. This will include enhanced access through appropriate sites and hours of operation, as well as effective planning to ensure adequate transportation for patients seeking to use MMH. Regional opportunities to enhance access to physician services will also be explored, using the cadre of physicians already required to meet the needs of Contra Costa County residents. Specific strategies to enable the County to provide this access include: • Monitor access to care by Medi-Cal and others in private sector across County • Identify regional or specialty areas with substandard access Develop appropriate approaches to meet the need, e.g.,: promotional efforts to increase awareness of service availability at MMH and clinics - transportation planning to enhance access to existing County services development of tailored clinic staffing, sites and/or schedules • Monitor impact of physician access on capacity, expense and revenue both at clinics and at MMH to assess net financial results. GERIATRICS PROGRAM The Geriatrics Program will serve as an important vehicle to enable the replacement of Merrithew Memorial Hospital. Through this Program, the Hospital would develop an increased ability to attract and serve Medicare and other payor classes in order to decrease net County cost for overall Hospital operations. The Geriatrics Program is a key entry point to serving the "mainstream" population of the County. The Program Analysis presented on the following page outlines relevant strengths, weaknesses, opportunities and threats for the Geriatrics Program. Q II.19 i PROGRAM ANALYSIS MARKET OPPORTUNITY: GERIATRICS PROGRAM Weakknes&%c_/1'hreats Rapidly Growing elderly population Lack of Board Certified/Eligible in the County medical specialists in key specialties Existing gero-psychiatric program at Lack of participation of community MMH physicians Existing array of relevant County - Negative image as "County" facility, services, including home health care poor physical plant with capacity constraints Rehabilitation personnel and experience Limited integration among the numerous related services offered by Experienced clinical personnel who the County affecting seniors have shown initiative in developing existing programs Limited experience in, or resources for marketing Administrator with experience in long term care operations Low Medicare market share Linkage with UC Davis through FP Service area 65+ population growing residency program slower than overall County Marketnlac�JComg No other facility in County has a special program targeting this population yet; however, others (including John Muir) are in development. Alta Bates has a geriatrics program which includes treatment of Alzheimer's patients. Alameda County has a gero-psychiatric program with UCSF fellows. VA population is aging; Stanford VA has Geriatric Research, Education and Clinical Center with Stanford residents. II.20 The specific strategies to be employed in developing the Geriatrics Program and focus on service to the elderly include: • Expand the specialized inpatient unit focusing on gero-psychiatric services. This could be accomplished by: - Increasing available bed capacity, e.g., additional acute beds or a step- down unit - Strengthening formal linkages with existing County programs, e.g., in- service training to home health personnel, social workers and other related County personnel regarding Program capabilities - Expanding the in-home assessment program with funding obtained by developing a legal structure suitable for fund-raising and grants management, and soliciting seed money from public and private sources Linking rehabilitation resources to geriatrics by reorganizing existing rehabilitation staff to serve under the direction of geriatrics or provide specialized geriatrics training to rehabilitation personnel as needed. • Expand elderly access to primary care, which could be accomplished by: - Opening a new clinic facility in Richmond supporting both geriatrics and Health Plan objectives - Seeking strategies to improve access to transportation for diagnostic and secondary clinic services. • Monitor the feasibility of developing a high-acuity skilled nursing facility which might include a gero-psychiatric step-down unit, stroke rehabilitation or treatment of Alzheimer patients. OBSTETRICS/WOMEN'S HEALTH PROGRAM The County Obstetrics/Women's Health Program will continue to meet the rapidly growing need for obstetrical, and other primary and secondary services. This will include enhanced physical access through appropriate sites and hours of operation, as well as through effective planning to ensure adequate transportation for patients seeking to use MMH. The facility and program planning for the Hospital will seek to reflect the community's increased reliance on the Hospital for prenatal care, while monitoring opportunities to expand services to these patients in other areas of women's and family health. The Program Analysis on the following page analyzes the strengths, weaknesses, opportunities and threats which will affect development of the Obstetrics/Women's Health Program. II.21 PROGRAM ANALYSIS MARKET OPPORTUNITY: OBSTETRICS PROGRAM WeaknessesTbrPats Current services have a high mix of Population growth rate for women 15 obstetrics, focusing on low risk - 44 is relatively low patients Target population is traditionally AUdH's traditional market segments heavy HMO, a market which MMH have higher fertility rates than the currently cannot access - Martinez population as a whole OB admits were 33% Kaiser and 41% HMO overall in 1985 Access to obstetrical care is deteriorating due to increased Lack of a full scope of Board liability problems, especially for Certified/Eligible medical specialist is Medi-Cal patients and other low compounded by lack of access to income groups MMH by community physicians Absence of entrenched traditional Poor physical plant combined with medical staff makes program image as "County" hospital definition easier, and facilitates family oriented care Increasing liability climate and risk- adverse physicians are seeking high- A new clinic in Vallejo should tech OB settings for even routine increase deliveries, justifying clinical deliveries resource enhancement In common with many hospitals, AUM's low caseload of about 900 deliveries a year is well below target minimum of 2,000 for quality standards MarketnlaCelComne� tihon Martinez insurance patients prefer John Muir, Mt. Diablo and hospitals in Alameda. County to MMH for deliveries. MMH has 4% share of Martinez insurance cases in OB, although it is the hospital of choice for local Medi-Cal with a 79% market share. Outside of the local area this pattern continues with dilution as Medi-Cal patients also heavily use Brookside and Los Medanos. II.22 The Obstetrics/Women's Health Program will be developed through the following strategies: • Ensure population access to obstetrical patient care, which can be accomplished by: - Promoting availability of care through County clinics and medical staff _ - Developing additional delivery sites or hours as appropriate, such as the clinic recently opened in Solano County. • Improve physical access to the Hospital for patients relying on County physicians, e.g., develop transportation strategy and mechanism for prenatal orientation, diagnostic services, prenatal care and births • Enhance the attractiveness of the physical facility through evaluation and f implementation of short term functional and amenity enhancements • Augment clinical resources by developing a Level II neonatal intensive care nursery and ensuring that Medical staff representation is consistent with case load requirements. The projected impact of implementing the proposed changes to the Obstetrics/Women's Health program is 225 additional deliveries with average length of stay of two days by 1990. Also, expansion in key regional markets (Antioch and Richmond)is projected to result in 1,500 non-obstetrics patient days by 1992 as a side effect of the obstetrics/women's health focus. RESPONDING TO UNMET NEEDS-AIDS The County AIDS Program will seek to respond effectively to the complete medical needs of AIDS and ARC patients, consistent with County and community resources including cost-effective case management. MMH's skills developed in meeting the chronic health needs of the geriatric population will enhance the ability to effectively serve the similarly chronic but unique needs of AIDS and ARC patients. The Hospital will seek to attract non- indigent AIDS patients in addition to its current services to indigents in an effort to provide a continuum of care while maximizing subsidy through third-party payors. i The Program Analysis on the following page outlines relevant strengths, weaknesses, opportunities and threats for the AIDS/ARC program. :µ •d II.23 PROGRAM ANALYSIS MARKET OPPORTUNITY: IMPROVE AIDS/ARC PAYOR MIX Stren. ths/QpnQriuWties Weaknessesffhreats Clinic program and primary care Lack of Board Certified/Eligible network specialists in respiratory, oncology, infectious disease and related Existing patient base of indigent specialties cases (Average Daily Census of 2) Poor physical plant and image as Existing array of County services "County" facility including social work and home health Lack of defined program or market presence Access to patients through County public health function Attraction of significant caseload or even marketing efforts could decrease Overall profile of County services in M1 M's attractiveness to other education and prevention desired population segments; they are unlikely to lose existing patients, Full scope of acute care capability but it could conflict with other including psychiatric services planned efforts MMH is at lower risk in this effort Potential problems in staffing, hiring than other hospitals since it can and retention, especially if a expect to receive the poor-paying dedicated AIDS unit were developed cases under any circumstances The need exists for a short stay SNF and hospice program to effectively manage costs Marketnlac c Competition No organized competition yet - most hospitals are treating cases but are ambivalent about efforts to attract them. Competitors run higher risks than does MMH that seeking to attract AIDS patients will have negative marketing consequences on other primary patient bases. Lack of data regarding where patients are being treated, current caseload or expected caseloads. II.24 -.:.- ... .:,✓?S ......., ...;JY. "TSI}+. 4...,2.4.�<?•..K'C;^Ivo"SS'r57'Jj?'iZ gyp.. .".'.in LY ::y;..,-x{;':::.. MMH's specific strategies with regard to developing an AIDS program will include the following: • Develop an integrated AIDS and ARC service continuum, e.g., acute care unit, medical staff AIDS specialist, home health, mental health, social work, community volunteer support and case management • Provide physician support to providers within the community through medical education, case evaluation and consultation • Increase public awareness of the County's continuum of services, e.g., integrating information with educational outreach, testing and counseling • Develop transportation plan for service access. a The projected impact of implementing the proposed changes to the AIDS program is an average daily census of nine patients by 1990 as a result of the marketing focus. The market share is capped at an average daily census of nine patients for each year thereafter due to likely efforts to limit excessive domination by one patient type. This projection is based on a reported average daily census of two patients and estimated patient days based on 57 days per case per year and 65 live cases in 1987. ENHANCED MEDICAL STAFF PRACTICE OPPORTUNITIES The County will seek to provide an expanded practice opportunity for the physicians serving Merrithew Memorial Hospital as staff members through the development of practice and clinic sites which enhance their ability to attract private patients. The family practice orientation of the staff will be maintained as a high quality and cost- effective alternative to the specialist-oriented private environment while MMH's specialty resources will continue to be enhanced and supplemented to maximize the quality of secondary physician coverage. MMH will also seek to increase its linkages with private physicians through increased outreach, consultation and administrative procedures to enhance integration of its staff and community physicians. Facility enhancements will enable NIMH to provide service to all patients treated by physicians on its staff by reducing the private patient's reluctance to use MMH due to its run-down facility. This programmatic alternative is affected by the factors which affect the County Health Plan as well as the existing medical staffs practice patterns. The Program Analyses on the following two pages discuss the strengths, weaknesses, opportunities and threats which are relevant to this alternative. II.25 PROGRAM ANALYSIS MARKET OPPORTUNITY: HEALTH PLAN POSITIONING Strenhs/OmigAanities WealmessesMimats Contra Costa County possesses a The Health Plan's reliance on the federally qualified HMO with Knox- less popular clinic structure, as Keene licensure - an important opposed to a network of private commodity which is expensive and physicians, for care of both indigent difficult to obtain in today's market and private patient groups essentially makes it noncompetitive except to The Health Plan currently pays those who cannot afford to purchase MMH 66% of charges for all acute other kinds of care, or for those for care for MIAs. It also pays 66% for whom there are substantial economic Medi-Cal patients incentives to use the Plan Through the clinics, the Health Plan The negative image of MMH and its is offering better quality and access to poor facility hampers the ability of the care than found in many counties for Plan to compete unless it contracts i MIAs and Medi-Cal patients who are with other acute care providers experiencing decreased access to mainstream MDs The Health Plan has the potential to be a critical resource in marketing efforts to key groups Marketnlagc ComnetWon The fastest growing segments of HMO enrollment are IPAs and other structures similar to private physician care - the Health Plan cannot offer this structure or appearance at this time. With already high levels of HMO penetration in the market area, the Health Plan is forced to either go after less desirable markets which competitors have overlooked or elected not to pursue, or attempt to attract patients from other plans and increase market share - this is difficult in any case, even between plans with similar resources II.26 PROGRAM ANALYSIS MARKET OPPORTUNITY: PHYSICIAN PRACTICE PATTERNS Stren�th_s/OunortunitiesWealmessesffbreats The family practice residency Reliance on the clinic structure and program has a high quality residency program for essentially all reputation and serves both as a physician care limits ability to attract source of practitioners for indigent patients who have economic or care and as a vehicle to attract faculty physical access to "mainstream" participation from local physicians physician community who might not otherwise consider the "County" Low levels of Board Certified/Eligible specialists in fundamental areas The relatively homogenous staff limits MMH's ability to develop discourages political infighting and sophisticated programs attractive to fragmentation which currently desirable population segments impairs the ability of many community hospitals to act quickly on Administrative barriers discourage market opportunities community physicians from practicing at MMH - NUM does not The financial structure of physician function as a community hospital payment, combined with the traditional medical staff privilege Current efforts by Administration to process enables MMH to more strengthen specialty representation aggressively screen for quality among may lead to conflict with the family applicants to practice at MMH practice program and the philosophies of the existing staff- this The family practice program de- stress could hamper ability to act or emphasizes technological solutions, develop new programs resulting in lower utilization levels and more cost effective care for Faculty members with private ' indigents and Health Plan purposes practices do not admit those patients _ to MMH - this demonstrates extent of negative image, which must be overcome to attract patients _l MarketDlace/ComBetition Competing hospitals are increasingly focusing on economic incentives to anchor physician loyalties. These may include joint investment ventures, aggressive referral efforts and other formal and informal programs. MMM has limited legal options for doing this, as well as few attractive opportunities to offer. The overall physician community is experiencing substantial turmoil and stress in the face of industry changes. This turbulence increases opportunities for MMH to alter practice patterns and loyalties through addressing physicians' concerns. II.27 To enhance the private practice opportunities for MMH's current medical staff and increase linkage with private physicians, the following specific strategies will be utilized: • Increase interaction with private sector physicians through linkages with specialty programs, e.g., gero-psychiatric assessment, AIDS, Medi-Cal obstetrics, graduate medical education and continuing education • Analyze the feasibility of streamlining administrative procedures enabling community physicians to refer patients to MMH • Evaluate appropriate sites and timing for developing supplemental clinic sites and/or schedules in Richmond and other locations to provide for private_ patient care • Continue monitoring the need for access to physician specialists and ensure MMH offers a full and appropriate complement of resources consistent with programmatic and service commitments SCENARIOS FOR MERRITJE EW MEMORIAL HOSPITAL For purposes of discussion and financial analysis, three possible scenarios were developed for Merrithew Memorial Hospital. The patient day and market share implications of these scenarios are presented in Exhibits 12, 13, 14, 15 and 16 on the following pages. • Base Case - No major replacement is attempted and continued use is made of deteriorating plant. This alternative most likely will lead to continuing loss of market share in Medicare and Medi-Cal population segments, resulting in services being provided almost exclusively to indigents, unless physician access issues act to compensate for the physical plant. • Replacement Only - The facility is replaced but no major market and programmatic development is undertaken. This alternative would allow stabilization of market share and continuation in the future at current levels, resulting in services being provided primarily to indigents and Medi-Cal patients. • Replacement and Market Focus -The facility is replaced in conjunction with major programmatic and product.focus, development and promotion as outlined in the previous pages. This alternative should result in increased market shares in Medicare and Medi-Cal, and increased Health Plan enrollment while allowing continued provision of care for indigents. Financial analysis was performed for the "Do Nothing (Status Quo)" and "Replacement and Market Focus" scenarios. II.28 .cr N r-1 Hcc m L V O w _M _ ao o c • CL m C13 Y t0 � O co N N C T N r y r co N� T ? O a _ 0 _ -c O ct't T cc E N ° cn �r T 3 � d ns J .L 24 oL aro � os LO f T a7 � aD H O df � T H m C13 T p r as i o coo p O Os m C13 O O O O O O O O O O r O W co I` to IA of M N r O C13 r T T T r V- 11 . 29 II . 29 ,.. ,. ...,;..,.�...:,: 'M•;c.,sszt.'x�o_`•_�,`Gt:�.+'u�-":??^�cti;'.y'4'+'�:r.+t:�-'!w�'r+.�'*�..:?cam"ia�;v,..2+? REa'"�3� 1"Fi::?.t?#Jit$��f§?�"�`�F::...'..�.�c;..',,�..:':'�ic.c„...�.y:,:c� . '' . • ool • • ►e//%%l/J/// lo j� Of .. 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ARCHITECTURAL 'PLANNING MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN TABLE OF CONTENTS INTRODUCTION.....................................................................................................................................................111.1 DEPARTMENTAL FUNCTIONAL AND SPACE PROGRAMMING Introductionand Highlights...................................................................................................................111.2 SummaryTables.......................................................................................................................................111.3 Administration Education&Training............................................... ........................111.6 ............................................ HospitalAdministration...............................................................................................................111.8 ' ..............................................................................111.11 ' Medical Education.....................................................................................................................111.12 Registration.................................................................................................................................111.13 U.R./Risk Management..........................................................................................................111.16 yVolunteers..................................................................................................................... . ......111.18 Diagnostic&Therapeutic Services Cardiopulmonary......................................................:................................................................111.20 Laboratory...................................................................................................................................111.23 Pharmacy.....................................................................................................................................111.25 Radiology.....................................................................................................................................111.27 Rehabilitation Therapies..........................................................................................................111.32 Surgery.........................................................................................................................................111.35 Inpatient Services CriticalCare.................................................................................................................................111.38 Detention................................................................. ..111.40 + Gero-psychiatric.........................................................................................................................111.41 Medical/Surgical........................................................................................................................111.44 Perinatal.......................................................................................................................................111.47 3 Rehabilitation........................................................................................... ..............................111.50 Mental Health Seryices CrisisUnit.....................................................................................................................................111.52 PsychiatricInpatient..................................................................................................................111.55 -i- MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN i TABLE OF CONTENTS (continued) Outpatient Services Emergency..............................................................................................................:...................111.57 FamilyPractice...........................................................................................................................111.60 Outpatient....................................................................................................................................111.63 SymptomControl..............„,......................,..........,........,.........................................,................,111.66 Support Services Biomedical Electronics............................................. ..111.68 Building&Grounds....................................................................................................................111.70 CSR/Stores.................................................:..........................................................................:.....111.72 Chaplain..................................................................:....................................................................111.76 EnvironmentalServices............................................................................................................111,78 FoodServices................................................................................:............................................111.80 Medical Records.........:........... ...111.82 Security........................................................................................................................................111.85 SocialServices............................................:..............................................................................111.86 FACILITY PLANNING Introduction to Facility Planning........................................................................................................111.88 DevelopmentObjectives.......................................................................................................................111.89 SiteDevelopment Analysis..................................................................................................................111.90 Development Recommendations ExistingSite Plan........................................................................................................................111.93 RecommendedSite Plan.... .................................................................................................111.94 Planning Assumptions................................ ..........................111.95 Site Circulation and Access.....................................................................................................111.95 Parking.........................................................................................................................................'111.96 BuildingOrganization................................................................................................................111.98 FuturePlan................................................................................................................................111.100 RecommendedFirst Floor Pian............................................................................................111.101 iY Recommended Second Floor Plan...................... ................111,102 Recommended Third Floor Plan...........................................................................................111.103 RecommendedFourth Floor Plan.............................................................................:..........111.104 Recommended fifth Floor Plan............................................................................................111.105 Recommended Sixth Floor Plan...........................................................................................111.106 Implementation and Project Schedule..........................................................................................111.107 -ii- MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN INTRODUCTION , I INVOLVEMENT IN THE PROCESS County involvement and participation in the development of the Master Plan included meetings with managers of individual hospital departments and a series of separate working sessions with the Steering Committee. The departmental managers provided significant and critical information. The managers helped } describe the current facility problems of their departments, as well as their perceived future requirements. SMP developed a report for each department,which documented the current problems and included a statement of current and future functional and space requirements. This report was reviewed in detail by the departments and modified, as appropriate. The completed reports are included in this section of the report. The Steering Committee reviewed and critiqued the functional and space programming, but its most important role was in guiding the facility planning. The Steering Committee evaluated different facility development strategies and guided the development of the eventual option. After this introduction, there are two sections which describe and support the Master Plan. A "Departmental Functional and Space Programming" section describes the current situation of the individual hospital departments,as well as documenting their current and future functional and space requirements. A Facility Planning section contains an analysis of the existing site,describes the overall development objectives,describes the resultant facility plan for replacement of the existing facilities, and details a potential development schedule. 1 ,l 1 J nL� MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN INTRODUCTION AND HIGHLIGHTS TO FUNCTIONAL AND SPACE PROGRAMMING The functional and space requirements of Merrithew Memorial Hospital departments were analyzed to identify both current needs and deficiencies,as well as to project requirements to meet future demand. This analysis was conducted by SMP and was based on n their experience, direct observations, interviews with departments and data review. The projections of space requirements were also based on workload projections prepared by Arthur Young. The departments were extensively involved in this process. The departments completed extensive questionnaires, participated in interviews, reviewed drafts of reports and approved the final report for their department. These detailed reports are included after this introduction. Highlights of the functional and space programming are noted below. Following these is a summary of current and recommended inpatient beds and a summary ofspace allocations. 0 The hospital is significantly short of space to meet current needs. Virtually every department in the hospital has a significant space shortage. o This problem of space shortages is particularly severe in the nursing units. The Medical/Surgical Nursing Units and the Perinatal Nursing Unit have less than half of the space they require. Critical Care has less than a third of the space it requires. 0 The nursing units are not configured to promote'staff efficiency or to promote quality care. 0 The nursing units are significantly lacking in patient amenities. 0 The nursing units are significantly lacking in staff support areas. 0 Among the diagnostic and therapeutic departments, Cardiopulmonary, Pharmacy, Radiology and Surgery have the most significant space shortages. 0 Each of the outpatient programs has a significant space shortage; Emergency has less than a third of the space it requires. 0 A variety of administrative and support departments have severe space shortages, e.g.Hospital Administration,Registration,U.R./Risk Management,Volunteers and Medical Records. 0 A number of departments are fragmented into separate locations, causing staff Inefficiencies. Examples include CSR/Stores, Cardiopulmonary, Radiology, Pharmacy, Registration,Surgery,Food Services and Medical Records. 0 A number of departments, aside from the nursing units, suffer from a very poor configuration of space. These include: Registration, U.R./Risk Management, Volunteers, Cardiopulmonary, Pharmacy, Radiology, Rehabilitation Therapies, Surgery, Crisis Unit, Emergency,Outpatient,CSR/Stores,Environmental Services, Food Services and Medical Records. 111.2 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SUMMARY TABLES i CURRENT AND RECOMMENDED INPATIENT BEDS Current Licensed Recommended -Beds Beds Service Critical Care 6 16 Gero-Psychiatric 8 12 Medical Surgical (incl.Detention) 102 114 Perinatal 14 17 Psychiatric 40 58 Rehabilitation 21 10 s Total 191 227 J J .1 111.3 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SUMMARY TABLES DEPARTMENTAL SPACE ALLOCATIONS (SQUARE FEET) Recommended Recommended Department Existing 1988 1994 ADMINISTRATION Education&Training..................................................................1,370...................,2,030... 2,270 ....., Hospital Administration........................:. 2;680...::... ..: .:;5,400 5,590 Libra ........ 1;020, . =1,500... ...........1,500............... MedicalEducation.........................................................................380....................1,000..,....,............1,000.....,.....,... Registration..................................................................................3,120..,....,...........,4,420.................,..4,500............... U.R.i Risk Management..............................................................680....................1,680....................1,780............... Volunteers........................................................................................590...................,1,790,......,............1,790............... SUBTOTAL.......................................9,840.................17,820.................18,430............... DIAGNOSTIC&THERAPEUTIC SERVICES Cardiopulmonary........................................................................1,890....................3,340.......,...,........3,500....,,......... Laboratory....................................................................................3,940.......,,..........,5,525.,...............,..7,150.....,.....,... Pharmacy.................................. . ...............................................1,960.,.....,............3,300....................4,200.......... Radiology.....................................................................................3,040....................9,800....................9,800............... ..s RehabilitationTherapies...........................................................7,210....................5,540.................. 5 ,.... Surgery.........................................................................................4,190.,.................,8,400......,..... ' 10 800,,4....... SUBTOTAL................. . ...............22,230..,....,.........35,905...........,,....41,250....,.....,.... INPATIENT SERVICES CriticalCare.....................................................................................990...................,3,600....................9,600....,......,... Detention.........................................................................................N/A.......................N/A.......................NIA............... Gero-psychiatric.........................................................................2,860....................4,000....................6,000............... Medical/Surgical ............................................................ .15,400.,...:x,.. 238,250. :.....:42,750. , �. Perinatal........................................................................................5,470.................11,535...........,.....14,000............... Rehabilitation..............................................................................5,070.................10,500.,..........,....,..5,000......,...,.... SUBTOTAL.....................................30,790.............,...67,885.................77,350............... MENTAL HEALTH SERVICES !' Crisis Unit....................................................................................2,100....................3,480....................3,480.......... n z.. Psychiatricinpatient.................................................................12,850.....,.......,...16,000.......,.........23,200.................. SUBTOTAL.....................................14,950.,...............19,480.................26,680............... 111.4 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SUMMARY TABLES DEPARTMENTAL SPACE ALLOCATIONS (SQUARE FEET) Recommended Recommended Department Existing 1988 1994 OUTPATIENT SERVICES Emergency...................................................................................1,680....................6,600....................7,600............... FamilyPractice........................-...................................................6,950....................9,000....................9,800............... Outpatient.....................................................................................3,800....................6,800....................6,800............... SymptomControl...........................................................................310.......................870.......................870............... SUBTOTAL....................................12,740..................23,270.................25,070............... s SUPPORT SERVICES BiomedicalElectronics.................................................................490.......................650.......................780............... Building&Grounds....................................................................4,970....................5,000....................5,000............... CSR/Stores.................................................................................10,490.................11,720.................11,720............... Chaplain..........................................................................................260.......................620.......................770............... Environmental Services.............................................................3,740....................2,740....................2,740............... FoodServices...........................................................................10,180....................9,460.................10,725............... MedicalRecords.........................................................................3,200....................5,780....................6,080............... Security............................................................................................110.......................150.......................150............... SocialServices...............................................................................380.......................750.......................750............... SUBTOTAL....................................33,820.................36,900.................38,715............... 1 TOTAL HOSPITAL DEPARTMENTAL GROSS SQUARE FEET......................................................124,370................201,260...............227,495............... l NON-HOSPITAL SERVICES 3 Eligibility(a).................................................................................1,900....................2,000....................2,000............... Geriatrics(a)...................................................................................573.......................600.......................600............... Mental Health Advocacy(a).........................................................512.......................600.......................600............... J Notes: (a) Not interviewed; present size continued at Contra Costa direction. 111.5 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN EDUCATION &TRAINING EXISTING CONDITIONS Programs and Services 0 The department is responsible for inservice and continuing education for hospital staff. Because of limited resources,the department focuses on nursing education. Current Facilities 0 The department is located on the second floor of E Ward, Facility Deficiencies 0 The department is distant from the medical library. 0 There is inadequate office space. 0 There are two classrooms,but neither is large enough for some groups. 0 The classrooms have poor acoustics. 0 The department's location next to the crisis unit is inappropriate. 0 There is an overall lack of storage and there is no secure storage. 0 The department lacks air conditioning. FUNCTIONAL ANALYSIS Staffing and Schedule Position 1988 1994 Director 0 1 Instructor 2 3 Secretary 1 1 TOTAL 3 5 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN EDUCATION &TRAINING i PLANNING GUIDELINES Relationships o The department should be near the cafeteria, in order to share large conference spaces. r o The department should be near the medical library. ,t SPACE LISTING The department currently has 1,370 gsf. We recommend current and planned allocation below. Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total ' Space Spaces Area Spaces Area 4 Director 120 0 0 1 120 Secretary 80 1 80 1 80 Instructor 80 2 160 3 240 Classroom (a) 25 50 750 50 750 Self Study 250 1 250 1 250 AV Storage 200 1 200 1 200 Storage/Copy 100 1 100 1 100 Conference 150 1 150 1 150 Total NSF 1,690 1,890 J Net to Gross Conversion Factor(b) 12 12 Total Departmental Space(rounded) 2,030 2,270 Note: (a) A larger area could be shared with Dining. This classroom should be subdividable and should be dedicated to Education and Training. J, (b) The net to gross conversion factor increases the departmental space to allow for circulation and interior partitions. The conversion factor will vary from department to department,depending on the character and complexity of the department. A ! 111.7 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN HOSPITAL ADMINISTRATION EXISTING CONDITIONS Programs and Services o The department is responsible for overall policy,as well as daily operations. It consists of senior management personnel, medical staff administration, nursing administration and their support staff. Current Facilities o The department is located in modular office buildings to the south of the main entrance. Facility Deficiencies o The department is removed from the main hospital. o There is inadequate private office space, especially for the medical staff. Clerical and support space is also severely limited. o There are no dedicated conference spaces in the department. o There are no bathrooms within the modular building. Staff must use the facilities in the main lobby. o The department lacks adequate storage space. o There is no waiting/reception space. o The medical staff mailbox is distant from the department. 111.8 ... MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN HOSPITAL ADMINISTRATION FUNCTIONAL ANALYSIS Staffing and Schedule Position 1988 1994 i Executive Director 1 1 Associate Executive Director 1 1 Assistant Administrator 2 3 Director of Nursing 1 1 Staffing Coordinator 1 1 House Supervisors 3 3 Secretaries 2 2 Clerical 6 6 Medical Director 1 1 Med.Staff Affairs 1 1 Service Chairs 4 4 . Comm.Chairs 5 - S TOTAL 28 29 o Certain administrative staff are programmed with other departments. These include: a Patient Ombudsman with Admitting;an Infection Control Nurse with Laboratory; a Quality Assurance Coordinator with Utilization Review; and nursing managers with their respective units. PLANNING GUIDELINES Relationships o The department should be centrally located. o The department should be near Medical Records and Utilization Review. 3 111.9 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN HOSPITAL ADMINISTRATION SPACE LISTING The department currently has 2,680 gsf. Recommended allocations are given below. Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total Space -Spaces Area Spaces Area Administratlon Executive Director 300 1 300 1 300 Senior Management 200 1 200 1 200 Middle Management 150 3 450 4 600 Secretary 100 1 100 1 100 House Supervisors 200 1 200 1 200 Nurse Staffing Coordinator(a) 100 1 100 1 100 Medlcal Staff Medical Director 200 1 200 1 200 Medical Staff Affairs Cood. 150 1 150 1 150 Service Chairs 80 4 320 4 320 Comm.Chair Work Area 200 1 200 1 200 Medical Lounge 300 1 300 1 300 Shared Support Clerical 80 6 480 6 480 Secretary/Reception 200 1 200 1 200 Files/Storage 300 1 300 1 300 Conference 300 1 300 1 300 Work Room 150 1 150 1 150 Break/Nourishment 200 1 200 1 200 Total NSF 4,150 4,300 Net to Gross Conversion Factor 1.3 1.3 Total Departmental Space(rounded) 5,400 5,590 Nate: (a) Office space for clinical nursing staff is allowed for in the respective nursing units. 111.10 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEGNAN MEDICAL LIBRARY EXISTING CONDITIONS Programs and Services o The department serves as an educational resource for hospital staff, primarily medical staff and residents. The department maintains journals and literature on site. It also provides search services and participates in interlibrary loan services. Current Facilities. o The department is located in the Family Practice Building at the northern end of the campus. Facility Deficiencies o The department is distant from the main hospital facilities. o There is inadequate shelving space. o Because of a lack of conference spaces, the library is often used for conferences; thus disrupting the normal use of the study areas. FUNCTIONAL ANALYSIS Staffing and Schedule Position 1988 1994 Director 1 1 i TOTAL 1 1 .j J PLANNING GUIDELINES Relationships o The department should be centrally located. o The department should be near Education &Training. SPACE LISTING The department currently has 1,020 gsf. An allocation of 1500 gsf should be adequate for its needs. !11.11 .-. ..:...... ...;_..• - _ ,J_, ...,..Z.'�?. ... .. ..:`gay _ +..}+� •,::1'�^- -.yi,...=:Y.",Y .:K �. s.... a-5K.3,�.' -. . MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN MEDICAL EDUCATION EXISTING CONDITIONS Programs and Services o The department serves as a resource for residents serving and studying at the hospital. Current Facilities o There are sleeping quarters in a trailer to the north of B Ward. Facility Deficiencies o The department is removed from the main hospital facilities. o There is no resident study area. PLANNING GUIDELINES Relationships o The department should be centrally located. SPACE LISTING Calculation of Recommended Space o The department currently has 380 gsf. An allocation of 1000 gsf should be adequate for its needs. This would allow for the development of a study area and four sleeping quarters, one pair for females and one pair for males. 111.12 -- .:...,+`";?_T,S�:s.�.�u>u��z%� ,.?u.r�„.?.�y';"�,`.-cam,"1;��;,;'a�..;rw,.`+;ra..`�rc.•��'�.^�'�a'-.�;:s MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN REGISTRATION EXISTING CONDITIONS Programs and Services o The department is responsible for the registration of all inpatients, outpatients and emergency room patients. The department verifies insurance, performs financial counseling and pursues Medi-Cal follow-up. The department is also responsible for the 1 cashier and the telephone system. Current Facilities ' o The department has three locations. The majority of the department is within or just off of the main lobby. The director and the financial counselors are located at the north end of the Administration Wing. There are also some registration personnel in the Family Practice Building. Facility Deficiencies' 1 o The department is split into three locations. 3 o The main department is located directly within the main lobby, compromising privacy and security for registration functions and limiting lobby functions. o There is inadequate private office space for the financial counselors. o Clerical and support space is also severely limited, especially in the telephone/cashier area. o The department lacks adequate storage space. 111.13 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN REGISTRATION FUNCTIONAL ANALYSIS Staffing (Peak Shift) Position 1988 1994 Manager 1 1 Supervisor 3 3 Secretary 1 1 Outpatient Clerks 11 11 Cashier/Telephone 1 2 Emergency Clerks 4 4 Fin.Counselors 8 8 Inpatient Clerks 2 2 TOTAL 31 32 PLANNING GUIDELINES Relationships • Ideally the department should be centralized, with the exception of the emergency registration which could be integrated with the emergency room. • As a fourth option,the department could have three locations: Emergency;Outpatient and Family Practice; and the main department (administration, financial counseling and inpatient)near the central lobby. • The telephone/cashier function should be placed with the emergency function to allow for off-hours coverage. • The department has a close relationship with Medical Records and utilization review. • A large number of pharmacy patients access the cashier. MERRITHEW MEMORIAL.HOSPITAL FACILITIES MASTER PLAN REGISTRATION SPACE LISTING The department currently has 3,120 gsf. We recommend current and future allocations below. Calculation of Recommended Space S ace 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area MAIN DEPARTMENT Director 120 1 120 1 120 Supervisor(Inp.&Fin.) 100 2 200 2 200 Inpatient Booths 60 .2 120 3 180 PBX 150 1 150 1 150 Financial Counselor 80 8 640 8 640 Cashier 250 1 250 1 250 Central Work 200 1 200 1 200 ` Files/Storage 100 1 100 1 100 Break/Conference 100 1 100 1 100 Waiting 400 1 400 1 400 Patient Ombudsman 120 1 120 1 120 Total NSF 2,400 2,460 Net to Gross Conversion Factor 1.3 1.3 Total Departmental Space(rounded) 3,120 3,200 OUTPATIENT Supervisor 100 1 100 1 100 Booths 60 4 240 4 240 Central Work 200 1 200 1 200 Files/Storage 100 1 100 1 100 Total NSF 640 640 Net to Gross Conversion Factor 1A 1.4 Total Departmental Space(rounded) 900 900 Family Practice Registration 400 400 TOTAL DEPARTMENTAL SPACE 4,420 4,500 Note: Emergency Registration is programmed with the Emergency Department. II1.15 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN U.R./RISK MANAGEMENT EXISTING CONDITIONS Programs and Services o For purposes of this report we are treating three departments (Utilization Review, Quality Assurance and Risk Management)as one.Utilization Review is responsible for inpatient review, Medi-Cal treatment authorizations and all payor prior authorizations. The department also staffs relevant medical staff committees. Risk Management is responsible for processing and investigating all lawsuits and all potentially actionable events. It also serves as staff to relevant medical staff committees. Quality Assurance is responsible for all mandated quality assurance activities. Current Facllitles o Both departments are located at the north end of the Administration Wing. Facility Deficiencies o The Supervisor and the UR physician lack private offices. They share one small office. .o The office for the risk manager is small and cramped. o There is inadequate clerical and support space. o There is an overall lack of storage and there is no secure storage. FUNCTIONAL ANALYSIS Staffing and Schedule Position 1988 1994 U.R.Supervisor 2 1 U.R.Physician 1 1 Risk Manager 1 1 Q.A.Coordinator 1 1 U.R.Coordinators 3 4 U.R.Clerks 4 6 TOTAL 12 14 111.16 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN U.R./RISK MANAGEMENT PLANNING GUIDELINES Relationships o The department should be near Medical Records. Secondarily, it should be near the Inpatient units, hospital administration and the physician mailboxes. J SPACE LISTING The department currently has 680 gsf. Recommended allocations are given below. Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area i U.R.Supervisor 120 2 240 1 120 U.R.Physician 120 1 120 1 120 U.R.Coordinator 80 3 240 4 320 U.R.Clerks 60 4 240 6 360 Risk Manager 100 1 100 1 100 Q.A.Coordinator 100 1 100 1 100 i Storage/Files 100 1 100 1 100 Secretary/Reception 150 1 150 1 150 Total NSF 1,290 1,370 i Net to Gross Conversion Factor 1.3 1.3 Total Departmental Space(rounded) 1,680 1,780 I _i a 1 111.17 .• ...._., ..- 5 :: N LtC �r>.w.ry... _ _ :_: .t}; . ,, CS;i"iw S7; �_C i'a 77 .} .:.. ,.:...<....�u... .._ - ...,.,. .,-.,•. '...:n's:_'... �".a:. ..av�.�..._.,,h.... E.,,..x...u.:3�:a.k,,�3:.,,.,..33».iu�;�^$h;::+:.Ci. MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN VOLUNTEERS EXISTING CONDITIONS Programs and Services o The department is responsible for three activities. First, it is responsible for a gift shop. Second, it is responsible for the coordination and development of all volunteer activities. Third, it has a role in public affairs and the development of community support for the hospital. Current Facilities o The department has two locations. The gift shop is located in the main lobby. The directors office and the volunteer activity area is located in the G Ward basement. Facility Deficiencies o The department is split into two locations distant from each other. _ a The gift shop is too small. a The gift shop is not secure. o There is inadequate proximate storage space for the gift shop. a There is no private, separate space for the volunteers. Their space is an open area between Medical Records storage and CSR/Stores- 0 The director does not have a private office. 0 The G Ward basement is very congested and noisy. FUNCTIONAL ANALYSIS Stamng and Schedule Po988 1994 iJ Director 1 1 TOTAL 1 1 f 111.18 .. ,, ...-.. .. '•- ''.,:t,g; ,'w-aces .,j'�2�;Z, '�t2 t �t_'?'2?ks,}"'+t*h�r'�''�"� MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN VOLUNTEERS i PLANNING GUIDELINES Relationships o The two sections of the department should be relatively close to each other, but need not be contiguous. o The gift shop should be in the main lobby. o The rest of the department should be near a parking lot,for volunteer access. SPACE LISTING The department currently has 590 gsf.The recommended allocations are given below. Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area Director 120 1 120 1 120 Reception 100 1 100 1 100 Volunteer Lounge/Lockers 250 1 250 1 250 Work Room 150 1 150 1 150 Storage 100 1 100 1 100 Book Storage 100 1 100 1 100 1 Total NSF 820 820 J Net To Gross Conversion Factor 1.3 1.3 Total Departmental Space(rounded) 1,070 1,070 Gift Shop 400 1 400 1 400 Storage/Work Room 200 1 200 1 200 :.i Total NSF 600 600 Net To Gross Conversion Factor 12 12 Total Departmental Space(rounded) 720 720 TOTAL DEPARTMENTAL SPACE 1,790 1,790 111.19 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CARDIOPULMONARY EXISTING CONDITIONS Programs and Services o The department has responsibility for: Respiratory Therapy, Pulmonary Function, EEG, EKG, Evoked Potentials. o The department would also like to develop further use of ultrasound equipment, specifically 2 dimensional Doppler. The department would also like to develop a pulmonary rehabilitation program. i I Current Facilities o The main department is located in a trailer at the southeast edge of the campus. The respiratory therapy area is located on the ground floor of E Ward. A storage area is next to the dietary offices. Facility Deficiencies o The department is divided into three locations. o The main department is distant from the inpatient units. o The main department is within a separate building from the hospital, which causes problems for staff and patients during inclement weather.. It also makes the transport of delicate equipment problematic. o There are no bathrooms within the main department,which causes problems for staff who perform certain tests. o There are no sinks in the main department,which makes it difficult to clean equipment. o There is no physician reading area. o The EEG room is not soundproof. o There are too few procedure rooms. ui 11120 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CARDIOPULMONARY i FUNCTIONAL ANALYSIS Operational Policies and Procedures o The respiratory therapy equipment is currently cleaned by central supply. The department would like to take over this activity, but it lacks the appropriate space. 1 PLANNING GUIDELINES Relationships o Ideally,the department should be centralized in one location. The department should be near Critical Care and Emergency. it should also have easy outpatient access. o As a second option,the department could be split into two locations, with the respiratory therapy area close to Critical Care and Emergency, and with the main department relatively near Emergency and Critical Care and with good outpatient access. i i i .1 111.21 FACILITIES MASTER PLAN CARDIOPULMONARY SPACE LISTING The department currently has 1,890 gsf. We recommend current and future allocations below. Calculation of Recommended Space Space 1988 1994. NSF1 No.of Total No.of Total Space Spaces Area Spaces Area Main Department Manager 100 1 100 1 100 Supervisor 80 1 80 1 80 Pulmonary Rehabilitation 200 1 200 1 200 Major Procedure Rooms(Stress) 200 2 400 2 400 Minor Procedure Rooms(EKG/EEG) 120 1 120 2 240 Toilet 50 1 50 1 50 Consultation/Conference 150 1 150 1 150 Secretary/Reception 150 1 150 1 150 Physician Reading 100 1 100 1 100 Technical Charting 150 1 150 1 150 Storage 100 1 100 1 100 Total NSF 1,600 1,720 Net to Gross Conversion Factor 1.3 1.3 Subtotal Departmental Space 2,080 2,240 (rounded) Respiratory Therapy R.T.Work Area/Storage/Cleaning 650 1 650 1 650 Consultation/Charting 100 1 100 1 100 Minor Procedure Rooms 120 1 120 1 120 Reception 100 1 100 1 100 Total NSF 970 970 Net to Gross Conversion Factor 1.3 1.3 Subtotal Departmental Space 1,260 1,260 (rounded) TOTAL DEPARTMENTAL SPACE 3.340 3,500 11122 . MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN LABORATORY EXISTING CONDITIONS Programs and Services o The department functions as a standard hospital laboratory.Approximately half of the total volume is outpatient work. Only 5% to 10% of the work is sent out to reference laboratories. Current Facilities o The department is located on the ground floor of E Ward. ' Facility Deficiencies 0 The patient waiting area is too small and there is no bed or toilet., o There is only one phlebotomy chair. o There is insufficient storage space within the department, especially for lab reports and hazardous waste. o There are no bathrooms for employees within the,main department. o There are insufficient private offices, specifically for the pathologists, chief technician and the supervisor. o There is no separate conference or lounge area. An open area of the lab has been designated as a lounge. o The specimen accessioning and processing area is too small. o There is inadequate venting in the specimen storage area. I o The pathology area is too small, especially the cytotechnician work area. o There is inadequate body space in the morgue. i 11123 ...�....,.,...:* nacnnvniALE1U,PITAL. FACILITIES WASTER PLAN LABORATORY PLANNING GUIDELINES Staffing (Peak Shift) Position 1988 1994 Pathologists 2 2 Chief Technician 1 1 Supervisor 1 1 Lab.Technicians 10 14 Clerks 4 5 Lab Assistants 2 2 ' Medical Transcriber 1 1 Histotechnician 1 1 Cytotechnicians 2 3 Morgue Attendant 1 1 f TOTAL 25 31 Staffing increases are based on an expected increase in workload by 1994 of 17°.6 in Pathology and 37%in Laboratory. Relationships o Primary relationships for the department are(in order of importance): Emergency, Surgery, Critical Care. SPACE LISTING Calculation of Recommended Space o The department currently has 3,940 gsf. There are currently 17 peak shift pathologists/- technicians. We allow 325 gsf per peA shift pathologistltechnician. Thus, we would recommend a current allocation of 5,525 gsf. o Peak shift pathologistftechnicians are expected to increase to 22. This would yield a future allocation of 7.150 gsf. 111.24 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN PHARMACY EXISTING CONDITIONS Programs and Services 0 The department functions as a standard hospital pharmacy, but with a major outpatient program. it also has an IV admixture program and it performs pharmaceutical ordering for a variety of off-site county health functions. Current Facilities 0 The department has four locations:the main department, which is just off of the main lobby;two separate spaces on A Ward; IV solution and forms storage in the Warehouse; and general storage in the basement of G Ward. Facility Deficiencies 0 The separation into four separate areas is inefficient. Though, the department would accept storage for IV solutions and forms out of department 0 There is inadequate office space,as the assistant director lacks an office. 0 There is no break or conference area. 0 The department has a severe space shortage,especially for compounding and storage. 0 The department suffers from inadequate security. PLANNING GUIDELINES Staffing (Peak Shift) Position 1988 1994 Director Assistant Director I I Pharmacists 5 7 Phar.Technicians 4 5 Clerks 3 4 TOTAL 14 18 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN PHARMACY Relationships o The department would like to be centralized in one location,with the possible exception of IV solution and forms storage. o Primary relationships for the department are (in order of importance): Acute Care units, Surgery, - Emergency, Non-Acute Care units, Outpatient Clinics. SPACE LISTING i Calculatlon of Recommended Space o The department currently has 1,960 gsf. We recommend an allocation of 300 gsf per pharmacist/technician. Thus, the 11 current pharmacist/technicians would yield an allocation of 3,300 gsf and the projected staffing of 14 pharmacists/technicians would yield 4,200 gsf. 11126 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN RADIOLOGY EXISTING CONDITIONS Programs and Services o The department offers the following services: General Radiography, Fluoroscopy, Mammography, Ultrasound, Tomography, Computed Tomography, Special Procedures. o The department would like to offer MRI and Nuclear Medicine. o The department will develop a residency program,which will require additional space. Current Facilities o The department has three locations: the main department, which is across from B Ward; an administrative trailer to the south of the department;and a CT trailer also to the south of the department. Facility Deficiencies o The CT equipment is located in a trailer outside of the department, causing staff Inefficiencies and patient transport difficulties. J o The ultrasound room is outside the main department. o There is inadequate office space,as the chief technician lacks a private office. o There Is no break or conference area. s o The department has insufficient file storage. o The department lacks an inpatient holding area. o The outpatient changing area is small and cramped. o There are no handicapped toilets. 11127 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN RADIOLOGY o The mammography equipment is used on a regular radiographic unit. This means that when mammograms are being done,the room cannot be used for radiography,and vice versa. 0 There is no physician consultation room. o There is no resident study area. -0 There is no reception area. o There is insufficient film reading space. PLANNING GUIDELINES Retationshfps r , o The department should be centralized in one location. o Primary relationships for the department are(in order of importance): Emergency, Surgery, Acute Care units, Non-Acute Care units, Outpatient Clinics. Design Consideration o The unit should be planned to allow for easy expansion and for the development of MRI. SPACE LISTING The department currently has 3,040 gsf. We recommend current and future allocation below. 11128 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN RADIOLOGY Calculation of Recommended Space 1987 1994 Comments 1. Annual Procedures CT Scans 1,537 1,875 22%Increase Fluoroscopy 676 784 16%Increase General Procedures 26,798 31,086 16%Increase Nuclear Medicine 386 448 16%Increase Mammography 875 1,015 16%Increase Ultrasound 2,826 3,278 16%Increase Special Procedures 255 296 16%Increase 'i 2. Percent Workload Done on Day Shift CT Scans 80 80 Fluoroscopy 100 100 General Procedures 80 80 Nuclear Medicine 100 100 Mammography 100 100 Ultrasound 100 100 Special Procedures 100 100 3. Annual Day Shift Procedures CT Scans 1,230 1,500 Fluoroscopy 676 784 General Procedures 21,438 24,869 Nuclear Medicine 386 448 a Mammography 875 1,015 j Ultrasound 2,826 3,278 Special Procedures 255 296 4. Average Hours per Procedure(incl. set-up and clean-up) CT Scans .75 .75 Fluoroscopy .60 .60 General Procedures 25 25 Nuclear Medicine 125 125 Mammography .50 .50 Ultrasound .75 .75 Special Procedures 2.00 2.00 11129 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN RADIOLOGY i Calculatlon of Recommended Space, continued 1987 1994 Comments 5. Annual Day Shift Procedure Hours (line 3 x line 4) CT Scans 923 1,125 Fluoroscopy 406 470 General Procedures 5,360 6,217 Nuclear Medicine 483 560 Mammography 438 508 Ultrasound 2,120 2,459 Special Procedures 510 592 6. Procedure Rooms Required Existing: (line 5/1,600)'0' CT Scan 1 1 1 Fluoroscopy/ 4 4 3 General Procedures Nuclear Medicine 1 1 0 Mammography 1 1 1 Ultrasound 1 2 1 Special Procedures 1 1 0 TOTAL 9 10 6 7. Planning GSF per Procedure Room CT Scans 1,800 1,800 Fluoroscopy/ General Procedures 11000 1,000 Nuclear Medicine 700 700 Mammography 300 300 Ultrasound 400 400 Special Procedures 1,800 1,800 Notes: (a) 1.600 = 50 weeks x 5 days x 8 hours x.80 scheduling contingency. 111.30 MERRITI-IEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN RADIOLOGY r Calculation of Recommended Space,continued 1987 1994 Comments S. Total Departmental Space pine 6 x line 7) CT Scans 1,800 1,800 Fluoroscopy/ General Procedures 4,000 4,000 Nuclear Medicine 700 700 Mammography 300 300 Ultrasound 400 800 Special Procedures 1,800 1,800 f SUBTOTAL 9,000 9,400 Existing: 3,040 DGSF ALLOWANCE FOR RESIDENCY 400 400 TOTAL DEPARTMENTAL GSF 9,400 9,800 .J a .i y4y .1 111.31 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN REHABILITATION THERAPIES EXISTING CONDITIONS Programs and Services o The department offers the following services: Physical Therapy, Occupational Therapy, Psychology, Speech Therapy, - Rehabilitation Medicine, Recreation Therapy. o Services are provided to the rehabilitation unit, to the other inpatient units and to outpatients. o The department would like to offer recreational therapy services and develop a "work hardening"program. Current Facilities o The department has three locations: the main department, which is in F Ward; spaces on the rehabilitation unit, G Ward;and storage and one office in the G Ward basement. Facility Deficiencies o The department is divided into three locations. o The department is distant from the inpatient units. o The department does not have ready access to outside areas for therapy activities. o The department has a large main area,but it is poorly configured. o There is inadequate private office space,as the supervisors,a social worker and one clerk all share one large office. Technicians have offices within therapy areas. o The speech therapy room does not have adequate sound proofing. o The department is poorly configured,with the registration and waiting areas at some distance from each other. o The registration area is too small. 111.32 a MERRCTHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN REHABILITATION THERAPIES o The mental health occupational therapist has an office within the storage area in the G Ward basement. i FUNCTIONAL ANALYSIS Staffing (Peak Shift) Position 1988 1994 Medical Director 1 1 Physicians 2 2 Chief, Rehab. 1 1 -Supervisors 2 2 Phy.Therapists 4 5 Occ.Therapists 4 5 Asst./Aides 4 5 Psychology 1 1 3 Speech Therapist 1 1 Recreation Therapist 1 1 Social Worker 1 1 Clerks 2 2 TOTAL 24 27 o Staffing increases are based on a projected 27%increase in workload. i PLANNING GUIDELINES l Relationships _3 o The department should be centralized in one location. o Primary relationships for the department are(in order of importance): 1 Inpatient Rehabilitation unit, Acute care units, Parking for outpatient access. a 111.33 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN REHABILITATION THERAPIES SPACE LISTING The department currently has 7,210 gsf in an awkwardly configured layout. Recommended spaces are given below. Calculation of Recommended Space Space 1988 1994 NSF/ No. of Total No.of Total Space Spaces Area Spaces Area Hydrotherapy Room 200 1 200 1 200 Dressing Rooms/Toilet 150 1 150 1 150 Gymnasium 600 1 600 1 600 P.T.Treatment Room 80 3 240 4 320 Occupational Therapy General 400 1 400 1 400 OT Kitchen 200 1 200 1 200 OT Bath 100 1 100 1 100 Physiatrist 120 1 120 1 120 Physician Charting 100 1 100 1 100 Director 120 1 120 1 120 Supervisors 80 2 160 2 160 Psychologist 120 1 120 1 120 Social Worker 120 1 120 1 120 Speech Therapy 150 1 150 1 150 EMG/Evoked Potentials 120 1 120 1 120 Tech Work/Charting 60 8 480 10 600 Staff Toilet 25 1 25 1 25 Reception/Waiting 20 10 200 10 200 Clerk 80 2 160 2 160 Storage 500 1 500 1 500 Total NSF 4,265 4,465 Net To Gross Conversion Factor 1.3 1.3 Total Departmental Space(rounded) 5,540 5= e.s 111.34 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SURGERY EXISTING CONDITIONS Programs and Services o The department offers inpatient and outpatient surgical services. It performs obstetrical surgical procedures and it offers cystoscopy services. Current Facilities o The department has three locations: the main department, which is across from C Ward; an outpatient area is within C Ward;and a recovery area is also in C ward but at the north end next to Critical Care. ..i facility Deficiencies o The separation of Surgery from the recovery area is a significant problem for patient safety and staff efficiency. o The department has insufficient storage for supplies and equipment. o None of the four operating rooms are sized to meet present code requirements. o There is no waiting room. o The main department is not secured. Traffic can enter the department from any of three uncontrolled entrances. j o There is inadequate office space for staff and physicians. o Lounge/locker space is inadequate for both staff and physicians. o There is no anesthesia prep room. o There is no clear separation of clean areas. .l i o The outpatient surgical area is severely overcrowded, with the nursing station, patient `i intake and recovery areas all mixed into one 400 gsf room. 111.35 .. z MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SURGERY PLANNING GUIDELINES Relationships 1 o The department should be centralized in one location. o Primary relationships for the department are(in order of importance); i Emergency, Critical Care, Radiology, Central Supply. Design Considerations o The department would like to be able to use any of the four rooms for Cysto procedures. } This could be accomplished with mobile equipment. 111.36 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SURGERY SPACE NEEDS SUMMARY The department currently has 4,190 gsf. We recommend current and future allocations below. Calculation of Recommended Space 1987 1994 Comments 1. Annual Procedures a. Total Procedures 2,969 3,615 b. Total Peak Shift Q 90% 2,672 3,254 Assumed c. Total Non-Peak 297 361 2. Average Procedure Time 110 110 Assumes in Minutes 20 minutes clean-up and 90 minutes procedure time 3. Annual Peak Shift 4,899 51966 Procedure Time(Hours) (line Ib.x line 2:60) 4. Annual Peak Shift 1,500 1,500 Hours Available per Procedure Room (8.0 hrs.per day x 5 days per wk. x 50 wks.per yr. x.75 contingency) 5. Procedure Room Required 3 4 (line 3,line 4) 6. Planning GSF per 2,400 2,400 Procedure Room 7. Subtotal Departmental Space 7,200 91600 (line 5 x line 6) B. Ambulatory Surgery Allowance 1,200 1,200 9. Total Departmental Space 8,400 10,800 111.37 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CRITICAL CARE DUSTING CONDITIONS Current Programs 0 Critical Care Nursing is a combined intensive care and cardiac care unit,with six licensed critical care beds. Current Fscllftles 0 The department is located at the north end of C Ward. There is a bereavement room in the trailer to the north of B Ward. Faclllty Issues 0 The individual patient areas are open and do not have auditory or visual privacy. 0 The unit is severely overcrowded. 0 There is no isolation room. o The nursing station is poorly configured,as the monitors are too high. Also,the station is on a raised platform. o There is no organized equipment or supply storage. o The ventilation and lighting are poor. o The unit does not have a soiled utility room. A hopper is across the hall. o The unit is very noisy. o There is no employee lounge. O There are only two sinks in the department o The department manager does not have an office. o There is no medical air. o The unit cannot segregate surgical from coronary patients. o There is no charting or dictation area. 111.38 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CRITICAL CARE PLANNING GUIDELINES Desired Relationships o Critical Care should be located near Surgery and, secondarily, near Emergency, Radiology and the Medical/Surgical Units with telemetry capability. SPACE NEEDS SUMMARY 'j Calculation of Recommended Space 1 _ o The department currently has 990 gross square feet for six critical care beds, or approximately 165 gross square feet per bed. Current planning standards call for 600 gross square feet per critical care bed,or 3,600 gross square feet. o Workload projections indicate 3,999 patient days in 1994, for an ADC of 11.0. This would d yield a unit of 15 beds. Because of design considerations, we recommend a unit of 16 beds for a total space allocation of 9,600 gross square feet. '1 i ._I J i 111.39 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DETENTION EXISTING CONDITIONS Programs and Services/Facllltles o At present, there is no separate area for the treatment of inpatients who are under detention. Facility Deficiencies o Because of a lack of dedicated space,detention inpatients are mixed in with the rest of the inpatients. PLANNING GUIDELINES Relationshlps o The department should be a separate and distinct area of Medical/Surgical Nursing. o The department would also like a distinct area within the Emergency Department for the treatment of detention patients. SPACE LISTING Space for this function will be programmed with Medical/Surgical Nursing. tie 111.40 MERRITHEWMEMORIAL HOSPITAL FACILITIES MASTER PLAN GERO-PSYCHIATRIC i EXISTING CONDITIONS Programs and Services o The department provides inpatient medical, psychiatric, behavioral and rehabilitative evaluation and treatment services to a target population of frail elders who have multiple co-existing problems. o The department has S beds. o The department is closely integrated with other parts of the county Geriatrics program, specifically the outreach service,the older adults clinic, physician home visits and inpatient unit consults. Current Facilities o The unit is located in H Ward,which is connected to L building. Facility Deficiencies o The unit is distant from the main hospital and all traffic to the main hospital must go outdoors. o The nursing station is not situated to have visual control of all patient rooms, nor does the nursing station allow visual control of all exits. o The unit is poorly configured. The layout does not promote either staff efficiency or quality . of care. o The day room is too small. _( o The dining room is too small. o The department"lacks access to a secure and level outside space. o The individual patient rooms are too small. o There is no dedicated conference area or employee lounge. o There is a shortage of office space for staff assigned to the department. o The department lacks a hopper/dirty utility room. o The department lacks adequate equipment storage. 111.41 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN GERO-PSYCHIATRIC r�srw��i�n d o The unit does not have adequate utilities,specifically wall suction/oxygen,telephones, televisions,Intercom. o The unit lacks access to a laundry. o There are no handicapped bathrooms. o There are insufficient shower and tub facilities and no shower and tub facilities for the handicapped. o The unit was not designed for the elderly, e.g. lack of railings, lack of resting alcoves, inappropriate:floor and window treatments causing glare, etc. PLANNING GUIDELINES Major Spaces o The department would like to have-a mix of private and semi-private rooms, with seclusion room availability. Relationships a The department should have a ground floor location with ready access to a secure and level area. o The departmental relationships are(in order of importance): Radiology,Cardiopulmonary, Rehabilitation Therapies; Acute Care,Critical Care, Outpatient Clinics; County geriatrics offices,SNF; Psychiatric inpatient units. Design Considerations o The department must be designed with a frail,elderly population in mind. a The department must be designed to allow for expansion. This can be accomplished in two ways: (1)the facility can be oversized to allow for expansion within the four walls of the department, and (2)the department can be placed on the site to allow for an easy addition. The Steering Committee prefers the second option. 111.42 " I MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN GERO-PSYCHIATRIC SPACE LISTING Calculation of Recommended Space o The department currently has 2,860 gsf for eight beds,a ratio of 358 gsf per bed. Units of this type should be allotted 500 gsf per bed. Thus, we would recommend a current allocation of 4,000 gsf. o Workload projections for 1994 indicate 3,538 patient days, or an average daily census of 9.7. This ADC would require approximately 12 beds and 6,000 gsf. J i 111.43 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN MEDICAUSURGICAL NURSING EXISTING CONDITIONS Programs and Services/Current Facilities o Medical/Surgical inpatient services have beds on three different wards. B Ward serves primarily as a medical ward and has a capacity of 44 beds,with six 6-bed wards, one 4-bed ward and two semi-private rooms. C Ward serves primarily as a surgical and orthopedic ward and has a capacity of 22 beds, one 6-bed ward, one 5-bed ward, two 4-bed wards, one semi-private room and one isolation room. D Ward serves gynecological and pediatric patients and health plan members. It has a capacity 36 beds,with two 6-bed wards for pediatrics;one 6-bed ward,one 4-bed ward and two semi-private rooms for gynecology; and five semi-private rooms for the health plan. o The units practice a combination of total patient care and team nursing. They are moving towards a system of total patient care. They believe that the hospital will never move towards primary nursing. - o At present,they have a mix of 55%RN and 45%LVN. They have no nurse aides. They would like to move towards a mix of 70%RN. Facility Deficiencies(For all wards,unless noted.) o The nursing stations are not placed to provide visual control of the units. o The configuration of the units does not promote staff efficiency or quality of care. o Only the health plan rooms have direct access to bathrooms. o There are insufficient examination rooms. o There is insufficient equipment storage space. i o There are no dedicated employee lounges or nurse charting areas.These two areas are combined. o There are insufficient isolation rooms. o The individual patient rooms are too small. o The medication rooms are too small. o There is no physician consultation room. o There is no resident work area. 111.44 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN MEDICAWSURGICAL NURSING o There is no physician dictation space. o There are no family waiting areas. o The units lack adequate utilities, especially,telecommunication and electrical outlets. o There are no separate clean and dirty utilities. o Each unit has only two showers. o There are no offices on the units for supervisors. PLANNING GUIDELINES Major Spaces o The units would like to have a mix of private and semi-private rooms, with approximately half of the beds in private rooms and half of the beds in semi-private rooms. Relationships o Medical/Surgical Nursing should be near Surgery, Critical Care, Radiology, Laboratory and Pharmacy. Design Considerations o The department would like to develop units of approximately 25 beds. It would like to "t explore the pod concept.The pods would be developed as subdivisions of the 25-bed units.This would allow the development of separate areas for detention, pediatrics, oncology,etc. ...E 111.45 _, .. ,.f:.---:. ..a .a:.�.t. .u:3;N,.,,^.r..r�.<,:FS:'??'✓sib!,?.%".�?s S.:;t'2 5�.-:'��,KS..w^2c1,. :.`��E?;.`*t4".;n MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN MEDICAUSURGICAL NURSING SPACE LISTING Calculation of Recommended Space o At present, Medical/Surgical Nursing has 16,400 gsf for 102 beds, or 161 gsf per bed. Current planning standards call for at least 375 gsf per bed for units with half private beds • and half semi-private beds. This standard would indicate a need for 38,250 gsf. o Workload projections indicate 33,168 patient days in 1994. This yields a 1994 average daily census of 91 and a bed requirement of approximately 114. This would require 42,750 gsf. o The service could be configured into four 25-bed units and one 14-bed detention unit. 111.46 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN PERINATAL EXISTING CONDITIONS Programs and Services o The department provides a traditional labor&delivery service,along with one ABC room; a 14-bed postpartum unit; a normal newborn nursery; and antepartum testing and labor evaluations. o The department has two delivery rooms; one private and one semi-private labor room; three 4-bed and one semi-private postpartum rooms. Current Facilities o The service is located on A ward. Facility Deficiencies o The nursing stations do not allow adequate supervision of all of the postpartum rooms. o The patient rooms do not have toilet facilities. All postpartum rooms share the same facility. o There is no medication room in the postpartum area. o There is inadequate equipment storage. o The 4-bed wards limit patient privacy. o There is no family waiting area. o The only access to the labor&delivery area is through the postpartum area, causing excessive traffic in the postpartum area. o There is no consultation room. 33 o There is no dictation space. l o There is inadequate charting space. o The delivery rooms cannot support cesarean sections. 111.47 ,. .. •. :.:- :...:. :.....-: sir i. . .yti<t?>,,r_.:� ''3„ti,`��'r5^�`�•.''sti,�'t3.' ^ �`a? MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN PERINATAL �YY�Y FUNCTIONAL ANALYSIS Operational Policies and Procedures o The department would like to have cesarean sections performed within the department. PLANNING GUIDELINES Relationships o The department would like to have a ground floor location. The department should be near the operating room. If a NICU is developed,it should be near the Perinatal Department. Design.Considerations o The department would like to develop an LDR program. Y o The department needs space for outpatient testing, holding and evaluation. SPACE LISTING Calculation of Recommended Space o The department currently has 5,470 gsf. Current planning standards would call for 11,535 gsf in a traditional suite. o Contra Costa targets 1,500 deliveries in 1994. An LDR unit would require 14,000 gsf. (This is based on 6 LDRs and 17 beds,which is based on the assumptions on the following page-) i�. 111.48 .. .:_.,....» -_ .......-..r.,.,-•- .•: ,. :;'.v✓fS 12Tr.:' ..: "3_ -+."r_3.i!..r`{...`F�,.`.. ...:."s?a'.'F"4'\'C".:'1."1T..'.�,..:C`.:'„C'r"'.;'^^al;,'CC:+"G*PC':y^OCStC SYt?. MERRrrHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN PERINATAL Assumptions for Recommended Major Spaces 1987 1994 No.of Deliveries 934 1,500 C-Section% 0.18 0.18 Normal Deliveries 766 1,230 C-Sections 168 270 Antepartum admissions 280 450 (At 30%) Antepartum LOS (hours) 60 60 Pre-Delivery LOS/Norm (hours) 18 18 Post-Delivery LOS/Norm (hours) 48 48 ' Pre-Delivery LOS/C-Sec(hours) 18 18 Post-Delivery LOS/C-Sec(hours) 72 72 Unscheduled C-Section% 0.3 0.3 Overflow rate/Deliveries 0.973 0.973 Occupancy rate/Beds 0.7 0.7 LDR Option LDR ADC 1.7 2.7 Beds ADC 7.5 12 No.of LDRs 4 6 No.of Beds 11 17 _7 I 111.49 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN REHABILITATION EXISTING CONDITIONS Programs and Services o This department offers inpatient rehabilitation services. It has 21 beds, with one 8-bed ward,one 5-bed ward and two 4-bed wards. Current Facilities o The department is located in G Ward. Facility Deficiencies o The nursing station is not placed to allow adequate visual control of the patient rooms. o The nursing station is small and cramped. a There is insufficient equipment storage. o The individual patient rooms are too small. There is inadequate storage of patient belongings. o There are no private or semi-private rooms. o There are no clean and dirty utility rooms. o The department does not have access to laundry facilities for patient belongings. o The dining area is too small. o The dayroom is too small. o The department does not have ready access to outdoor space. o The toilet and shower facilities are inadequate. o The unit does not have adequate utilities,especially electrical outlets. PLANNING GUIDELINES Relationships o The department must be near Rehabilitation Therapies. The department should be near the Gero-Psychiatric Unit. 111.50 .a .. }zr k*4. .', ..:.•:..�... .^'u'1 5: r.. ... . :.Ywd, s iC.tti..t r...,.^ix ..v.«...r.. ... .. .. .......n.... . MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN REHABILITATION s SPACE LISTING Calculation of Recommended Space a The unit currently has 5,070 gsf for 21 beds,or 241 gsf per bed. A unit of this type should be allotted 500 gsf per bed,or a total of 10,500 gsf. o Workload projections indicate 3,110 patient days in 1994. This yields an average daily census of 8.5 and a bed allocation of 10. Ten beds would require 5,000 gsf. l i ..f } i s 1 111.51 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CRISIS UNIT EXISTING CONDITIONS i Programs and Services o The department serves as a psychiatric emergency service. A primary function is the evaluation of potential admits to the inpatient service. The department also consults on the Medical/Surgical Units. Current Facilities o The department is located at the north end of D Ward. r: Facility Deficlencles o The unit is distant and in a separate building from the psychiatric inpatient units. This causes problems in patient transport i o The reception, triage and waiting area are all combined in one room. This presents a number of security and privacy problems. o There is no designated area for physical assessments. o There is only one interviewing room and it is too small. o The unit design does not allow separation of different types of patients, i.e. children form adults, or voluntary from involuntary patients, or male from female. o There are no isolation rooms. o There is no visitor reception/waiting area. o There are no female restrooms within the department. Females must go to the south end of the ward and travel through other hospital departments. o Some patient waiting is in the hallway,which can compromise the privacy of conversations in adjacent offices. o The unit lacks adequate office space. o The unit lacks an employee lounge. o Because of a lack of space, adjacent departments are sometimes used for patient sleeping. 111.52 �: MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CRISIS UNIT o There is no space for storage of medical equipment. FUNCTIONAL ANALYSIS Staffing (Peak Shift) Position 1988 1994 Director 1 1 MHTS therapist 3 3 Physician 1 1 Alcohol Counselor 1 1 Nurse 1 1 Clerk 1 1 Psych.Tech. 1 1 Psych.Intern 1 1 t Psych.Resident 1 1 TOTAL 11 11 PLANNING GUIDELINES Relationships o The primary relationship is with the psychiatric inpatient units and next with the emergency room. o Other important relationships include: Pharmacy, Laboratory, Medical/Surgical Units, and { Security. r j 111.53 - -..- .- .M:.•s..,..,;-z-::c-rcpcs�..sas:�;vaxr.-.x..., .."SC,•?a?Y v's.?n^.',iNE?:3';iK.S2�,''C_ ___ .. _.. -..;?'�:"'7t',xa'w,�.-*:.a..`. MERRiTHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CRISIS UNIT SPACE LISTING The department currently has 2,100 gsf. We recommend current and future allocations below. Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area Semi-Private Rooms 240 4 960 4 960 Dayroom 200 1 200 1 200 Reception/Waiting 150 1 150 1 150 Triage/Assessment 100 1 100 1 100 Patient Waiting 150 1 150 1 150 Director/Interviews 120 1 120 1 120 Physician/interviews 120 1 120 1 120 Staff Work/Charting 80 6 480 6 480 Shared Interview Rooms 150 2 300 2 300 Toilets 50 2 100 2 100 Total NSF 2,680 2,680 Net to Gross Conversion Factor 1.3 1.3 Total Departmental Space(rounded) 3,480 3,480 111.54 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN +. PSYCHIATRIC INPATIENT EXISTING CONDITIONS Programs and Services o The department offers inpatient psychiatric services. Current Facilities o The department has three locations. I Ward has 20 beds,with four 4-bed wards, one semi- private and two seclusionrsolation rooms. J Ward also has 20 beds, with three 4- bed :l ward, and eight isolation/seclusion rooms. The department also has two trailers to the 3 south of J Ward. Facility Deficiencies 1 o Both wards are poorly configured for acute psychiatric units. The nursing stations do not afford visual control of the patient rooms and the activity areas. o The unit designs inhibit staffing efficiency and the delivery of quality care. o Neither unit is designed to allow the segregation of different types of patients, i.e.voluntary from involuntary or adolescent from adult. o Office space for many therapy staff is in the trailers, outside of the inpatient units. o Neither unit has an employee lounge. o The occupational therapy area on I Ward is too small and too distant from the nursing station. o The nursing stations are too small. o There are insufficient shared interview rooms. o There are no family Interview rooms. PLANNING GUIDELINES i Relationships o The units should be consolidated in one area. o The primary relationship is the crisis unit and secondarily the gero-psychiatric unit. 111.55 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN PSYCHIATRIC INPATIENT Design Considerations o The unit would like to have half private rooms and half semi-private, i.e. 33% private beds and 67%semi-private beds. o The department would like to develop smaller nursing units, which will allow the development of distinct units for distinct patient groups. SPACE LISTING - Calculation of Recommended Space o The department currently has 12,850 gsf for 40 beds, for a ratio of 321 gsf per bed. Units of this type should be allotted 400 gsf per bed. This would indicate a current allocation of 16,000 gsf. o The department would like to provide for 58 beds in 1994. These will require 23,200 gsf. 111.56 MERRITHEw MEMORIAL HOSPITAL FACILITIES MASTER PLAN EMERGENCY EXISTING CONDITIONS Current Programs o The department provides 24-hour emergency care, including a physician on duty at all times. It provides rape and child abuse evaluations and medical evaluations of psychiatric patients. ' o The department may become more involved in trauma in the future. o The department would also like to develop a separate area for detention patients. Current Facilities o The department is located on the west side of the administration building. Facility Issues o The department suffers from a significant space shortage. i o The treatment rooms.are too small for major trauma. o The layout of the department is poor. The layout gives no control over traffic flow. o There is no distinct emergency waiting area. o The triage area faces the main lobby,compromising patient privacy. ' o There is no distinct and separate ambulance entrance. .i j o There is inadequate storage for equipment and supplies. o There is no doctor's sleeping quarters or ambulance attendant area. o There are insufficient private treatment rooms. .0 The nurses'station is not located to allow visual monitoring of the exam rooms. o The nurses'station is too small. i o There is no director's office. o There is no staff lounge. 111.57 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN EMERGENCY o There is no designated parking for emergency patients. o There are no restrooms for patients. o There are insufficient sinks. o There are no clean and dirty utility areas. o There is no holding or observation area. o There is no ENT or pediatric treatment room. o There is no consultation room. PLANNING GUIDELINES Desired Relationships o Primary relationships are: Radiology Laboratory Surgery Critical Care o Secondary relationships are: - Outpatient Clinic - Crisis Unit - Pharmacy - Medical Records Operational Concerns o Registration should be integrated with the triage area. 111.58 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN EMERGENCY SPACE NEEDS SUMMARY The department currently has 1,680 gross square feet. The 1988 and 1994 recommendations are developed below. Calculation of Recommended Space 1988 1994 Comments i 1. _ Annual al Ys� 25,981 28,323 j 2. Average Peak Shift 34 37 (0.48%of Daily Visits visits on peak - (line 1 e 365 x.48) shift) 3. Average Peak Daily 5 5 Visit Capacity per } Treatment Station 4. No.of Treatment 7 8 Stations Required (line 2:line 3) 5. No.of Observation 3 4 Beds Required (a) 6: Total Patient Spaces 10 12 7. Planning GSF per 500 500 -.� Patient Space 8. Sub-Total Departmental Space 5,000 6,000 J 9. Allowance for (a) Registration/Telephone/Cashier 400 400 (b) Trauma 500 500 { (c) Detention 700 700 10. Total Departmental Space 6,600 7,600 Note: (a) Assume 1 observation bed per 2 treatment stations. 111.59 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN FAMILY PRACTICE EXISTING CONDITIONS Current Programa o The Family Practice Clinic functions as a group practice and residency training program, with approximately 25,000 visits a year. The department is also responsible for health plan members. Current Facitltles o The department is in M Ward,at the northern end of the campus. Facility Deficiencies o The department lacks a dedicated nursing station. o The waiting area is too small. o Storage for major equipment(e.g., gumeys,wheelchairs) is insufficient. o The department is distant from Laboratory, Radiology, Medical Records and Pharmacy. o There is no conference area. o There are no offices for the medical director, supervising nurse or the administrator. o A patient educator and a financial counselor share an office. They should have private offices. a Clean and soiled linen are not separated. Operational Concerns a The department would like to have decentralized waiting. a The department would like to develop a model of two exam rooms per suite, rather than the current three per suite. 111.60 '�' MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN FAMILY PRACTICE r PLANNING GUIDELINES Desired Relatlonshlps o The department would like to be close to the main facility. o Its important relationships within the medical campus are Laboratory, Pharmacy, Radiology,and Medical Records. _i 111.61 .... _-=,.::2'� �2 .c-.;E'4k;�,7; �'..r- ,,{:.,.y.*,..o..__ 'r_,...; �:...'N.? .:;.�'=w+>�r.,•✓`•�":�*'a`�i.L{'?°�.....� s.>.h"._. ...t.. . .�:-..'y MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN FAMILY PRACTICE SPACE NEEDS SUMMARY The department currently has 6,950 gross square feet. We recommend current and future allocations below. Calculation of Recommended Space 1988 1994 Comments 1. Annual Visits 25,401 27,700 2. Average Turnaround 40 40 Assumed Minutes per Visit 3. Annual Exam Hours 16,934 18,457 (line 1 x line 2/60) - 4. Annual Hours Available 1,700 1,700 per Exam Room (a) 5. Exam Rooms Required 20 22 Existing: 17 (line 3/line 4, rounded up,times 2) (b) 6. Planning ng GSF/ 400 400 Exam Room (c) 7. Total Department Space 8,000 8,800 (line 5 x line 6) 8. Special Allowances Registration and Waiting 1,000 1,000 9. Total Department Space 91000 9,800 (line 7 + line 8) Notes: (a) Available hours figured on 8 hours per day x 5 days per week x 50 weeks x.85 scheduling contingency. (b) Rooms are doubled to enable physicians to work efficiently with two rooms. (c) Planning room standards include all support space. !11.52 :-.... ....:,' •. ��...x .�n.::.,,_.._'ke:�.t>�+.� '„``�.taw` 2 ","`.`�`c''...szf;`�r2r?,+,iif:._,s�`. -iiy"�?�zr"".�..r�.'.'_._.'..'�Zx+�s.;?s; MERRiTHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN;, OUTPATIENT EXISTING CONDITIONS Current Programs i o The department is responsible for a variety of specialized medical clinics as well as a dental and audiology clinic. Current Facilities o The department is located at the south of the Administration Wing. Facility Deficiencies o Patient flow through the department is not controllable, since only one long corridor accesses the different clinics. o The registration area is too small. o The patient waiting area is too small. i o There is no medical director's office. o There is no manager's office. o Because of a lack of waiting areas, hallways are often used for patient waiting. o There are no conference rooms for staff. o Too few bathrooms exist,and none are equipped for the handicapped. o There is no patient teaching area within the department. The department must use conference rooms distant from the department or use existing office space. o There are no counseling or consultation rooms within the department. l o There is insufficient clerical working space. 3 o The dental area lacks a separate waiting/registration area. o The dental area lacks adequate storage. a The dental area lacks a director's office. o The dental x-ray area will not accommodate wheelchairs. 111.63 FACILITIES MASTER PLAN OUTPATIENT i Operational Concerns o The department would like decentralized waiting. PLANNING GUIDELINES Desired Relationships o The department should be near Laboratory, Radiology, Pharmacy,and Medical Records. .o Registration should be near the department. f 111.64 �y MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN OUTPATIENT SPACE NEEDS SUMMARY The department currently has 3,800 gross square feet in an awkwardly shaped building. We recommend current and future allocations below. Calculation of Recommended Space 1988(d) 1994 Comments 1. Annual Visits 13,800 15,040 2. Average Turnaround 40 40 Minutes per Visit 3. Annual Exam Hours 9,200 10,030 (line 1 x line 2/60) 4. Annual Hours Available' 1,700 1,700 3 per Exam Roam (a) 5. Exam Rooms Required 12 12 Existing: 9 (line 3/line 4, rounded up,times 2) (b) 6. Planning GSF/ 400 400 r Exam m Room(c) 7. Total Department Space 4,800 4,800 (line 5 x line 6) 8. Special Alloway a. Dental 700 700 b. Waiting 500 500 c. G.I.Lab 400 400 d. ENT Lab 400 400 i 9. Total Department Space 6,800 6,800 {tine 7+ line 8) Nr`: (a) Available hours figured on 8 hours per day x 5 days per week x 50 weeks x .85 scheduling contingency. (b) Rooms are doubled to allow physicians to work efficiently with two rooms. (c) Planning room standards'include all waiting and support space. (d) Annualized from 9 months of data. 111.65 �r�{2f St 3 is MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SYMPTOM CONTROL EXISTING CONDITIONS Programs and Services o The department offers pain relief and counseling services for terminal patients. Department staff oversee the program,while nurses from home health and public health provide the actual care. Current Facilities _ o The department has one room on E Ward. Facility Deficiencies o The department lacks an office for the director. o The department lacks a dedicated conference area for use by staff and by patients and their families. o The department*lacks adequate storage. FUNCTIONAL ANALYSIS Operational Policies and Procedures o The department will continue to operate with "care-givers" borrowed from other departments. Staffing and Schedule o The department has one director and one secretary. A volunteer coordinator will be added in the future. PLANNING GUIDELINES Relationships o The department should have ready outpatient access. 111.66 �' MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SYMPTOM CONTROL SPACE LISTING The department currently has 310 gsf. We recommend a current and future allocation below. Calculation of Recommended Space i Space 1988 1994 J NSF/ No.of Total No.of Total Space Spaces Area Spaces Area Director 120 1 120 1 120 _ Volunteer Coordinator 100 1 100 1 100 Conference 200 1 200 1 200 Storage 100 1 100 1 100 Secretary/Reception 150 1 150 1 150 Total NSF 670 670 Net to Gross Conversion Factor 1.3 1.3 Total Departmental Space (rounded) 870 870 -1 _.l J `a ,.1 111.67 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN BIOMEDICAL ELECTRONICS EXISTING CONDITIONS Current Programs 0 The department services a variety of medical equipment in the hospital. it also services addressographs and suction and oxygen equipment. 0 Most radiology, laboratory, critical care, and cardiopulmonary equipment is serviced by contract,as are the telephones and televisions. 0 The department would like to take over some contract services. Current Facilities 0 The department is located in a trailer at the west of the campus. Facility Deficiencies 0 The department is distant from the main facility, causing significant problems in equipment transport. 0 There is no piped-in air or vacuuming in the department. 0 There is no running water in the department. 0 There is no drain in the department PLANNING GUIDELINES Desired Relationships 0 The department should have easy access to the nursing floors and to the major ancillaries. Staffing 0 The department presently has one director and one technician. 111.68 zz ��t4' MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN BIOMEDICAL ELECTRONICS i SPACE NEEDS SUMMARY The department currently has 490 gross square feet. We recommend 1988 and 1994 space allocations below. Calculation of Recommended Space Space 1988 1994 NSF( No.of Total No.of Total Space Spaces Area Spaces Area Work Benches 100 2 200 3 300 Storage/Ubrary 300 1 300 1 300 Total NSF 500 600 Net to Gross Conversion Factor 1.3 1.3 Total Departmental Space(rounded) 650 780 1 111.69 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN BUILDING AND GROUNDS EXISTING CONDITIONS Programs and Services 0 This department is responsible for operation,repair and preventive maintenance programs for all hospital buildings and equipment(other than equipment maintained by Biomedical Engineering). it is also responsible for grounds maintenance, painting, carpentry, and plumbing shops. 0 (Overall mechanical and electrical capacity will be discussed elsewhere in the final report.) Current Facilities 0 The department has tour locations. The engineer is adjacent to the boilers. The carpentry and paint shop are in vacated laundry space. The plumbing shop is in the basement of the L ward. There is also a gardening shed. Facility Deficiencies 0 The department is fragmented into four locations. 0 There are no office spaces for a potential on-site director and an additional supervisor. 0 There is no dedicated space for the Paint Shop or for the spray booth. FUNCTIONAL ANALYSIS Staffing and Schedule Position im 1994 Director 0 1 Supervisors 1 2 Operating Engineers 5 5 Electricians 1 1 Painter 1 1 Carpenter 1 1 TOTAL 9 11 111.70 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN: BUILDING AND GROUNDS PLANNING GUIDELINES Desired Relationships o Maintenance should be in close proximity to Biomedical and to the main plant building. SPACE NEEDS SUMMARY Calculation of Recommended Space o Building and Grounds presently has 4,970 GSF. This would seem to be an adequate allocation for its function. The present space layout and separation of areas may inhibit efficient use of space. While some space additions or reallocations may be necessary to solve current problems,a future allocation of 5,000 GSF of appropriately configured space should be more than adequate. z i K� 111.71 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CSR/STORES EXISTING CONDITIONS Current Programs 0 This report covers two departments. Together,they comprise inventory/stock control, the warehouselbulkstores function, the central supply function and the purchasing function. They also operate a mailroom and a copyroom. Current Facilities 0 Central supply is across from D Ward. Stores has quarters in the G Ward basement and in the storeroom above Dietary; it also has a modular building at the northwest end of the campus. Facility Deficiencies CSR - CSR lacks a breakdown or receiving area. - The interior of CSR is poorly laid out, causing mingling of clean supplies and dirty equipment. - Due to a lack of a breakout or receiving area, supplies are often stored in the hallway. - The department lacks storage space for clean equipment,e.g., IV infusion pumps. - Storage for patient supplies on the different nursing units is insufficient - There is no area for staging exchange carts. - The departmental manager has no private office. The office is within a storeroom. There are no employee lockers. There is no area for cart washing. Stores - The loading dock is small. - The loading dock is difficult to access and it is not-protected from the weather. 111.72 • MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CSR/STORES The storeroom is on a separate level from the dock, causing the vertical movement of all supplies. There is no separate area for the mailroom. The main department does not have ready access to a bathroom. The department is divided into three locations,which limits staff efficiency. The copy room must be accessed through the main department. a Operational Concerns o Central Supply is interested in maintaining and developing an exchange cart system. PLANNING GUIDELINES i i + Desired Relationships o ideally,the two functions will be adjacent. o Central Supply should maintain a strong relationship with Surgery. • a Stores should be near Central Supply. Staffing o Central Supply currently has one manager, one clerk,and six technicians on a peak shift. o Stores currently has one departmental manager, one storeroom supervisor, two t storekeepers,and eight clerks and two drivers at a peak shift. .Y a 111.'73 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CSR/STORES SPACE NEEDS SUMMARY Central Supply currently has 1,530 gross square feet; Stores has 8,960 gross square feet. 'We recommend space allocations for the two functions below. Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area STORES Administrative Area Manager 120 1 120 1 120 Secretary/Receptionist 150 1 150 1 150 Clerk/Typist 60 4 240 4 240 Copying 120 1 120 1 120 Mailroom 150 1 150 1 150 Forms storage 900 1 900 1 900 Subtotal NSF 1,680 1,680 Net to Gross Conversion Factor 1.2 1.2 Subtotal GSF 2,020 2,020 Stores Supervisor 100 1 100 1 100 Dock 250 1 250 1 250 Bulk Stores 4,000 1 4,000 1 4,000 Subtotal NSF 4,350 4,350 Net to Gross Conversion Factor 1.1 1.1 Subtotal GSF 4,790 4,790 SUBTOTAL DEPARTMENTAL GROSS SQUARE FEET 6,810 6,810 111.74 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CSR/STORES SPACE NEEDS SUMMARY Central Supply 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area Director 120 1 120 1 120 Clerk 60 1 60 1 60 Lockers/Toilets 100 2 200 2 200 Decontamination 500 1 500 1 500 Cart Washing 120 1 120 1 120 Equipment Washing 100 1 100 1 100 Equipment Wiping 100 1 100 1 100 Janitor-Soiled 50 1 50 1 50 Janitor-Clean 50 1 50 1 50 Washer/Sterilizer 100 1 100 1 100 Make-up 300 1 300 1 300 Terminal Sterilizer 130 1 130 1 130 ETO Containment/Clean 55 1 55 1 55 ETO Containment/Soiled 55 1 55 1 55 ETO Sterilizer 30 1 30 1 30 Hopper 60 1 60 1 60 Clean Processed Stores 1,200 1 1,200 1 1,200 Storage/Equipment 300 1 300 1 300 Issue 100 1 100 1 100 -I Breakout 160 1 160 1 160 Surgical Linen Packroom 300 1 300 1 300 Subtotal NSF 4,090 4,090 Net to Gross Conversion Factor 12 1.2 Subtotal Departmental Space 4,910 4,910 i TOTAL DEPARTMENTAL SPACE 11,720 11,720 _7 111.75 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CHAPLAIN a EXISTING CONDITIONS Current Programs o Pastoral Care is responsible for patient counseling. The department also provides an educational program for 6-7 graduate theologians. Current Facilities o The department is located in a trailer at the western end of the campus. Facility Deficiencies o There is no meditation facility on the campus. o There is no dedicated study space for the students. o The department is distant from the main facility. PLANNING GUIDELINES Desired Relationships o The department should be accessible to the patient floors. o The meditation room need not be adjacent to the departmental offices, but should be centrally located. Staffing Position 1988 1994 Chaplain 1 1 Assistant Chaplain 0 1 TOTAL 1 2 111.76 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN CHAPLAIN I SPACE NEEDS SUMMARY The department currently has 260 gross square feet» We recommend 1988 and 1994 allocations below. Calculation of Recommended Space Space 1988 1994 i NSF/ No.of Total No.of Total ;. Space Spaces Area Spaces Area Chaplain 120 1 120 1 120 w Assistant Chaplain 120 0 0 1 120 ! Study Area 200 1 200 1 200 t Total NSF 320 440 s Net to Gross Conversion Factor 1.3 1.3 j Total Departmental Space(rounded) " 420 570 Meditation Room 200 200 Total Departmental Space 620 770 ' 1 I 111.77 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN ENVIRONMENTAL SERVICES EXISTING CONDITIONS Programs and Services o Housekeeping is responsible for maintaining orderly, sanitary conditions in all hospital buildings and departments. The department is also responsible for other county health facilities. The linen service is run by an outside company on contract. Current facilities o The main department is located in the laundry building at the southeast edge of the campus. Linen storage is in a temporary building at the north of B Ward. Facility Deficiencies o The department has limited storage space for housekeeping supplies and equipment on the nursing units. o The main department is distant from the main facilities. o Linen storage is limited in patient areas. o Patient rooms are difficult to clean because they are too small to accommodate patients, equipment,and patients' personal effects. o The storage of patient equipment in hallways makes cleaning difficult. o There is inadequate office space for the director and supervisors. o There is an inadequate number of restrooms in the campus. FUNCTIONAL ANALYSIS Operational Policies and Procedures o Linen Service is a rental service. PAR stocking of nursing units is done daily for each floor. Soiled linen is stored on a large trailer rig at the south end of the campus. PLANNING GUIDELINES Desired Relationships o The department should be centrally located. .. . . ;;nN�•`.'. .-#..�., y.,��.,.Nr�+.r:ss":'�`s•.�'3?��,i.�f?»~.�_x. ? �:s�.,a.�ti,w...>.ccc-::. MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN ENVIRONMENTAL SERVICES } { SPACE LISTING The department currently has 3,740 gross square feet,excluding linen storage. However,this space is poorly configured. If new space is developed,we recommend the following allocation. No reduction of existing space is recommended. Detailed Space Luting Unit Net _ Room/Space Q�t rr Area Area Comments Supply Storage 1 600 600 Equipment Storage 1 400 400 Clean Linen 1 400 400 Manager 1 120 120 Assistant Manager 1 100 100 Senior housekeeper Supervisors 2 So 160 Supervisors Secretary/Reception 1 150 ISO Conference Room 1 15O ISO Lockers/Toilet/Shower 1 100 100 Female LockerslToilet/Shower 1 100 100 Male i Total NSF 2,280 Net to Gross Conversion Factor 12 - Total Departmental Space(rounded) 2,740 l 111.79 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN FOOD SERVICES EXISTING CONDITIONS Current Programs o The department is responsible for food service to the hospital and the operation of a cafeteria. It caters special functions and is responsible for vending services. The department has a dietician on staff. It is also developing a senior dining program in the cafeteria. Current Facilities o The kitchen,storeroom,and cafeteria are located to the south of E Ward. o A vending area is opposite the cafeteria. The dietician's office is in the eligibility module, at the eastern end of the campus. i Facility Deficiencies o Many patient units are distant from the department, hampering the delivery of hot meals. o Conference areas are also distant from the department. o The food-preparation area is poorly laid out. It uses too much space and prevents efficient use of staff. Also,it is difficult to replace equipment. o The department lacks adequate electrical capacity, especially for heating and air conditioning. o Management offices are removed from the preparation area, preventing observation of staff. o The dietician's office is distant from the department. o The clerical work area is too noisy. o The building is aging and it is difficult to keep clean. FUNCTIONAL ANALYSIS Design Considerations o Conference/dining areas should be subdividable. 111.80 �" MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN FOOD SERVICES PLANNING GUIDELINES Desired Relationships o The department would like to be consolidated. o The department would tike to be near the nursing units and the education/training areas. SPACE NEEDS SUMMARY The department currently has 10,180 gsf in poorly configured space. We recommend current and future allocations below. Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area Main Dining 15 150 2250 200 3000 Private Dining (subdivisible) 22 5o 1100 50 1100 Manager 120 1 120 1 120 Asst.Manager 100 1 100 1 100 Dieticians 100 2 200 6 600 Dietary Clerks 60 2 120 2 120 Storage 1150 1 1150 1 1150 Preparation/Cook 850 1 850 1 850 Patient Service/Tray Make-up 680 1 680 1 680 t Cafeteria Service 690 1 690 1 690 Clean-up 960 1 960 1 960 Toilets/Lockers 280 1 280 1 280 i Mechanical 100 1 100 1 100 3 Total NSF 8,600 9,750 Net to Gross Conversion Factor 1.1 1.1 Total Departmental Space(rounded) 9,460 10,725 111.81 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN MEDICAL RECORDS EXISTING CONDITIONS Programs and Services o The department maintains central medical records for all inpatients and outpatients. The department is responsible for medical-legal correspondence and for statistical reporting to governmental agencies. The department also maintains a Tumor Registry. Current Facilities o The main department has three locations. The main department is in the administration wing. Some staff are in a room at E Ward and active records are stored in the G Ward basement. Facility Deficiencies o The three locations pose a problem for staff efficiency. j o The department does not have adequate record storage. o Clerical work areas are extremely crowded. o The department does not have ready access to a conference room. o A physician restroom is located within the department. FUNCTIONAL ANALYSIS Operational Policies and Procedures o The department maintains 4 years of active records—two years within the department and the rest in G Ward. o Transcription is handled by contract. 111.82 , MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN MEDICAL RECORDS Staffing (Peak Shift) Position 1988 1994 Chief 1 1 Medical Records Admin. 3 3 ART 4 4 Medical Records Tech. 9 13 Clerks 11 11 Tumor Registrar 1 1 Secretary 1 1 f DEO 1 1 TOTAL 31 3S Notes: The director believes the current staffing levels can accommodate further growth if the department is centralized.. This should be checked, given the assumption of 9 percent outpatient and 51 percent inpatient growth. PLANNING GUIDELINES Desired Relationships o The department should be near: - Emergency Room; - Utilization Review/Risk Management; - Outpatient; l - Patient accounting. i _l '.5 111.83 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN MEDICAL RECORDS SUMMARY LISTING The department currently has 3,200 GSF. We recommend 1988 and 1994 space allocations as follows: Calculation of Recommended Space Space 1988 1994 NSF/ No.of Total No.of Total Space Spaces Area Spaces Area Chief 120 1 120 . 1 120 Medical Records Admin. 100 3 300 3 300 ARS' 80 4 320 4 320 Conference 150 1 150 1 150 Technicians/clerks 60 20 1,200 24 1,440 Incomplete Records 150 1 150 1 150 Secretary/Reception 150 1 150 1 150 Microfilm/Storage 200 1 200 1 200 Record Files 1,800 1 1,800 1 1,800 Tumor Registrar 150 1 150 1 150 Data Entry 80 1 80 1 80 Total NSF 4,620 4,860 Net To Gross Conversion Factor 1.25 1.25 Total Departmental Space(rounded) 5,780 6,080 Note: The above figures represent the space required for peak shift employees. 111.84 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SECURITY y EXISTING CONDITIONS Programs and Services o Security is responsible for ensuring the safety of the hospital staff and for protecting buildings and equipment against theft,fire, or unlawful intrusion. The department has a special role with regards to transporting patients to and from the crisis clinic. Current Facilities ' o Security has an office in the E Ward. Facliity Deficiencies o The office is too small for employee lockers,the Director's office and a report area. FUNCTIONAL ANALYSIS J Staffing and Schedule 3 o The department has one director and three full-time staff. Two staff are on duty during a peak period. PLANNING GUIDELINES Desired Relationships o The department should be near the crisis unit, emergency room and the main lobby. o The departmentshould have ready access to parking. 3 SPACE NEEDS SUMMARY Calculation of Recommended Space } o The department`currently has 110 DGSF. A 150 DGSF office should be adequate for its needs. 111.85 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SOCIAL SERVICES EXISTING CONDITIONS Current Programs o The department provides social services,discharge planning, and placement services for all outpatients,inpatients,and emergency patients throughout the hospital. Current Facilities o The department has space in a trailer at the west end of the campus and one office on A Ward. The department shares a number of other offices around the campus. Facility Deficiencies o The department clerks are located in a building distant from the hospital. This is inefficient for staff coverage and access by the social workers. o Most social service workers' offices lack auditory privacy, creating confidentiality problems. Only one social worker has a private office. o None of the social service workers'offices is large enough to handle family conferences. o The department lacks conference space. o The outpatient areas lack interview rooms which social service can use. PLANNING GUIDELINES Desired Relationships o The department supports decentralizing its functions such that one central office area is maintained for two clerks,a director,and central files, along with a conference area. The ` remaining social workers would be distributed throughout the patient care areas, one with Perinatal,four with Medical/Surgical,one with Rehabilitation,one with Outpatient, and one with Symptom Control. Staffing o The department currently has no director,eight MSW s,two senior social workers, and one clerical staff. Predicted 30%overall hospital growth would indicate the need for two more social workers. 111.86 64 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SOCIAL SERVICES SPACE NEEDS SUMMARY The department currently has 380 gross square feet. We recommend current and future allocations for the central department below. Nine other social workers should be distributed throughout the hospital. These offices would require 120 gross square feet each for a total of 1,080 additional gross square feet. This latter space is allowed for in the nursing unit programming. Calculation of Recommended Space Space 1988 1994 NSF/ No. of Total No.of Total Space Spaces Area Spaces Area Director 120 1 120 1 120 Secretary/Reception 150 1 150 1 150 Clerical 60 1 60 1 60 Mufti-Purpose Room 150 1 150 1 150 J Storage 100 1 100 1 100 Total NSF 580 580 Net to Gross Conversion Factor 1.3 1.3 Total Departmental Space (rounded) 750 750 _l 111.87 MERRITHEW MEMORIAL.HOSPITAL FACILITIES MASTER PLAN INTRODUCTION TO FACILITY PLANNING This section presents the development objectives that guided the facility planning process and provides an evaluation of the existing site as it relates to development opportunities and constraints. Specific departmental deficiencies are described separately within the Functional and Space Programming section of this report. This section also describes the recommended plan to meet the facility program for a total replacement facility on the present site. It also describes an approach to incremental development of the recommended plan over time and presents an assumed development schedule. 111.88 `' MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT OBJECTIVES i The following development objectives were identified to guide the master planning process. 1. Provide improved space for core hospital departments—for example, nursing units, Surgery, Radiology, Emergency and Pharmacy. 2. Provide facility improvements for other departments with major internal inefficiencies -- for example, Hospital Administration, Registration, U.R./Risk Management, Volunteers, Cardiopulmonary, Family Practice, Outpatient,CSR/Stores and Medical Records. 3. Eliminate older, inefficient buildings. - 4. Consolidate fragmented departments. S. Improve site access and parking. 6. Provide a new image and highly visible entrance area. 7. Develop a more compact campus. 8. Minimize cross traffic of patients, public visitors, staff,and supplies. 9. Provide a plan for new development that can be constructed incrementally. i 10. Maintain existing hospital operations during construction and related renovation. 11. Provide convenient vehicular drop-off points for emergency patients,visitor,and staff. 12. Maintain attractive green spaces on the campus, and retain existing redwood grove adjacent to `l Alhambra Avenue and "B"Street. :J 13. Provide for the later expansion of nursing units,as required. 1 14. Provide a plan for development that is fiscally responsible. 111.89 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SITE DEVELOPMENT ANALYSIS I-AREA M05T SUTTEO FOR CORE KWMAL PEVELOPMEM 2.MEA BEST SUM fM CONTMAlEO USE AS ,NwmO . 2.ODMMAATY PARK �.AREA MOST S4FTED FOR MAP""MMAL P~4 B.MEA MOST SUMO FOR OUTPAr&W SERV2ES . !BEST U)QITION FOR MENTAL NEAITNFWST MCREYEM OF NEW CONSIPMT ON T.SW LOCATION FOR SMUEO NUFGW4 FACUrY 9 E AREA MOST SUREO FOR 11#00Gt4 s MEA CEABT SUM FDR AM'DEVELOPMENT ID.BEST LOCATION FOR CENTRAL PWft mo MAMTEW WCE A OUTPATIENT SERVICES E PANSgN AREA B.CORE NOSWAL E OPANS30N AREA C BEST LOCATION FOR PARK NO GARAGE IF . REOWRED 't OSE.PRNATE PROPERTY TO BE ACOURED FOR FUTURE NosorrAl USE . .._r-�• \``ti ` HEST LOCATION FOR ®.. �! '\ SERVICE ACCESS HEST LOCATION FOR SNF lS AMENTAL CCESS HEALTH �\\\ • AT LOCATION FOR EMERGENCY ACCESS . ia• nn Av �� Y„. ' _M_ c= LKIG►T1PN FOPS,--- ^`. CORE MOSFIt'AL♦ .. uNAMMRA AVE.VE. ,OUTPATIENT #CC&""` — r } I - SGIE, 0 25 30 .,100 200 SITE DEVELOPMENT ANALYSIS . 111.90 B� MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SITE DEVELOPMENT ANALYSIS The following section summarizes the site analysis as illustrated on the previous page. 1. This area of the site is best suited for the core hospital replacement.It is contiguous with existing hospital facilities, permitting phased construction. It is the only area large enough for the replacement hospital which minimizes relocation of existing facilities prior to construction.This Area provides high visibility and convenient access from Alhambra Avenue for the primary entrance and from Soto Street for access to the emergency department. 2. This existing parking lot is well located for continued use as parking. it is easily accessible and adjacent to the area of the site best suited for the core hospital replacement. 3. The existing redwood grove Is a community and campus asset which should be preserved and enhanced. 4. The area currently occupied by the existing hospital provides the best location for the future primary parking lot. it is located in an easily accessible and Visible location. 5. This area provides the optimum location for an Outpatient/Family Practice Building. It is contiguous with the core hospital and can share hospital services. This location also has convenient access to parking in adjacent areas to the east and west. Additionally as outpatient services expand,this location allows for easy expansion to the south. 6. This area provides the best location for a Mental Health Building. It is contiguous with the core hospital but allows for a separate entrance and identity. In addition, this area allows for development to occur independently of the core hospital. 7. This area provides the best location for a separate Skilled Nursing Facility, with a minimum of disruption to the existing hospital services. B. This area provides the best location for parking,to serve the Skilled Nursing Facility (area 8) and Mental Health Building(area 7). 9. This is an area of very steep slopes and is unsuitable for any hospital development 10. This area provides the best opportunity to develop a new Central Plant and Maintenance Building. Expansion Potential A. This area provides expansion potential for outpatient services. B. This area provides expansion potential for the core hospital. MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN SITE DEVELOPMENT ANALYSIS r C. This area provides the best opportunity to develop garage parking, to accommodate either an increase in demand, and or to allow for replacement parking if expansion areas A + B are developed. We recommend that this future garage parking be no more than 3 levels, with one level below grade.This will allow the visibility of the new hospital from Alhambra to be maintained. D+E. These properties are not currently owned by the hospital and it is recommended that they be acquired in the future. Acquisition of these properties may negate the need for garage parking. is 111.92 �' MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS co LAUNDRY -'t u D t..... ' w wxpo- E PLANT ,. I.WARD PSYCH. _ _. .. r wrap IP IP PSYCH L� E WARD ... .._..... .. . .. WAREHOUSE IF PSYCH. Q Q M1sr Y WARD _ D WORD © FAMILY MAIN - PRACTICE ..' (1 HOSPITAL ^CWAWARD PARKING Dsr i WARD AWARD PARKING - 0 Mina EYTR. �� e SOCIAL SERVICES a_ --' -.. — L BUSINESS''OFFICE ALMAIMRA AYE. , SCALE 0 25 SO 100 20C EXISTING SITE PLAN 111.33 ..... :.. -»-c>r,;'.+�ruF...�r..`•..?5:.`t£'_`irF:}�.�"�,���t?e'.3,"' .,.„c"�"''a}�'_ .�.r'�c__.�`r`ti?�..?'e �z„ _.e,.�._ .tyt MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS ILLED NURSING FACiLLITY _ MENTAL NEALTN 17 5� a tS tags. CENTRAL ANT QQ FAMILY PRACTICE SERIME Ft34 CAN UTURE _ OVT►ATIEN �� � • EXPAN N IFi I ER PARKING ' s 30 CARE NOSWALI HENT NTRY 1 ' t NOSPTTAL ENTRYI, FUTURE Fs* �y tY. i I EEO CARS .. /Y�URE T� lMolU OAftAO[ Eilln.RP" . 'qE! ytF iRli: no twRe e p� r AL"WSAA AVE- ...! 177Z SCALE p 25 SO epp 200 RECOMMENDED SITE PLAN MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS The following text and accompanying site and floor plans describe the development recommendations. PLANNING ASSUMPTIONS 1. Upon inspection of the existing site,the existing hospital buildings should be replaced. 2. Construction of the replacement facilities may occur incrementally requiring continued use of some existing facilities until the final elements are complete. 3. All parking will accommodated on the site. 4. The main entrance will continue to be from Alhambra Avenue. 5. The existing redwood grove on Alhambra Avenue at B Street is to be maintained. 6. The Central Plant replacement will continue to be a separate facility. 7. Mental Health will have�a separate identity and building entrance, but physically connected to the core hospital building for support services. 8. , The Outpatient Clinics and Family Practice are to be housed separately but physically connected to the core hospital. Each will have its own separate entrance. 9. Site development and planning incorporates the location for a future,,Skilled N- u %, ,is Facility isto,be:-developqd�:i p N M *rt.,for,,,,.the�--replacem,,ent-�of,ttTer,,hotoitai. qd� �ent y;of4hW' Astec,,R SITE CIRCULATION AND ACCESS Vehicular Access 0 The hospital campus can be accessed directly from city streets adjoining north, east and south edges of the property. This provides opportunities to separate traffic flow to relieve congestion and improve accessibility. Main Entrance 0 The existing main vehicular access point off Alhambra Avenue is maintained and developed into a primary boulevard leading to the new main hospital and outpatient entrances. 0 A major new parking lot is developed on the south side of the boulevard with convenient access to the main hospital and outpatient entrances. 111-95 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS Emergency o A new separate access point for emergency is created at the end of Soto Street. o A new emergency parking lot is provided directly on the north side of the building adjacent to the Emergency Room entrance. Mental Health o The new Mental Health Building is located on the southwest side of the new hospital building with a separate parking lot and vehicular access via C Street. Family Practice o Family Practice is located on the second level above the Outpatient Clinics with a separate entrance at that level. Vehicular access is via"C"Street with parking adjacent to the entry. Service o The primary hospital service entrance is located on the west side of the hospital building. o All service vehicles will access the hospital receiving dock via Allen Street. This allows the separation of service vehicles from other hospital traffic. Central Plant and Maintenance o The Central Plant and Maintenance building is located on the northern edge of the campus. it will use the service vehicle access point via Allen Street. PARKING The hospital currently has 383 designated parking spaces. Staff and visitors also use a large number of parking spaces on adjacent streets and in the nearby residential areas. We recommend a future total parking allotment of 735 spaces. The basis for that recommendation is discussed below. o There are currently only 9 parking spaces near the emergency room. We believe that this should increase to 20 spaces. This is based on a projected daily peak shift load of 34 patients. This should be sufficient for ambulance traffic and for patients arriving by 111.96 m, MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS private car. Visitors to the emergency room would be encourage to use the public/staff lot(s). o Currently, there are no designated spaces for outpatient parking. We recommend an allocation of 65 spaces. This is based on a projected daily peak shift load of 170 outpatients, or approximately 63 patients during any 3 hour time period. Given that a large number of outpatients use public or county transportation, 65 designated spaces should be adequate for variations in peak load. o There are presently 15 designated spaces for physicians, we recommend an allocation of 25. o There are presently approximately 800 employees at the hospital. We estimate that 60%of these are present for a peak shift, giving a peak shift staff of 480. We assume a factor of 15%for growth,yielding a future peak staff of 550. (Inpatient activity is expected to grow by 51%,while outpatient activity is expected to grow by 9%. Since staffing is not related to volume in a linear fashion,we have allowed for only 15%growth.) We believe that the staff who carpools or use public transportation will balance out the need for peak shift overlap parking,therefore we recommend only 550 spaces for staff. o We recommend,75 spaces for visitors, based on one space for every three beds. This allocation could be reduced if visitor parking were combined with staff parking, as most visitors come after the peak employee shift. Parking Summary TYe Current Projected Emergency - 20 Outpatient - 65 Physician - 25 Staff - 550 Visitors - 75 a r TOTAL 383 735 SNF Assumption @99 beds. - 60 T o In the design of the campus plan,the primary parking areas were developed to be adjacent to the primary entry points to the hospital and Outpatient Buildings. o Separate parking areas are also developed to serve the emergency department, Mental Health, Family Practice and the Skilled Nursing Facilities. 111.97 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS BUILDING ORGANIZATION The basic organizing concept is to separate functions such as outpatient services and Mental Health away from the primary in-patient areas. The resulting design is a concept in which the core hospital is connected to separate Mental Health and Outpatient Buildings, each of which has its own separate building entrance and parking. The steep topography of the site provides the opportunity to locate separate building entrances on the first and second floor levels. The main hospital, emergency, and Outpatient Clinic entrances are located on the first floor. Mental Health, Family Practice, Skilled Nursing Facility and the hospital service entrances are located at the second floor level. The core hospital is a six story building. Basically,this is organized with three levels of nursing floors on a three-level base of Diagnostic,Treatment, and Ancillary Departments. The building is arranged vertically to separate in-patient areas from outpatient areas. Furthermore,the hospital is organized to enhance the primary interdepartmental adjacencies and relationships defined in the planning guidelines developed from the departmental interviews. First Floor 0 The base is organized so that diagnostic and treatment areas which have a large outpatient component,such as radiology and emergency,are located on the first floor. 0 The majority of the hospital's administrative components which includes Registration, Admissions,and Medical Records,are located centrally, close to the main entry. 0 Radiology is located adjacent to emergency. 0 Medical Records is located to be conveniently accessible to both the Emergency Department and the Outpatient clinic areas. 0 Both the Emergency Department and Radiology Department will have direct access to patient/service elevators in the elevator core. Second Floor 0 The second floor of the core hospital is basically a service and staff related floor. 0 The primary service departments of CSR, general stores,food service, laboratory, and pharmacy,all have access to the central core of service elevators. 0 The service entrance and loading dock are located on this floor,with direct access to the food service area,CSR and central stores. 111.98 MERRITHEW MEMORIAL HOSPITAL _ FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS o CSR is located directly below surgery and labor/delivery. This provides the opportunity to have dedicated cart lifts to move equipment and material directly between these areas, without using the main elevators. Third Floor o The third floor isri r' p ma ily the critical-care floor and contains the departments of Surgery, Critical Care and Cardiopulmonary. o Elevators are directly accessible to serve both Surgery and the Critical Care areas from nursing units on;,upper floors,or for transporting patients from the emergency department. Fourth Floor o The fourth floor is the primary Medical-Surgical Nursing Unit floor with four Nursing Units clustered about the central core of service and patient elevators. Fifth Floor o The fifth floor contains the Rehabilitation Therapy area,the Rehabilitation Nursing Unit, the Gero-Psychiatric Nursing Unit and the Detention Nursing Units. o Those patients being admitted to the Detention Nursing Unit will arrive through the Emergency Department and be brought directly up to the unit via a dedicated elevator. Sixth Floor o Only half of this floor is developed and contains a seventeen bed Perinatal Unit, new born t nursery and Labor/Delivery Suite. o The Labor/delivery Suite will contain both traditional and contemporary birthing facilities. :Vy Circulation 7 i o The hospital is arranged around a central core of elevators which will be configured to provide a separation between inpatient,staff, service,and visitor traffic. o The elevators will be designed to provide separate elevator lobbies for inpatients and service on each floor and separate elevator lobbies for visitors. o In addition to the primary elevators in the core hospital, secondary elevator cores will be located in the Mental Health Building and in the Outpatient/Family Practice Building. 111.99 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS Outpatient/Family Practice Building o The Building is organized on two levels with the Outpatient Clinics and eligibility services on the first floor and the Family Practice Clinic on the second floor. o This building is connected on both levels to the core hospital, to provide convenient access to hospital services. o Because of the grade changes,this building can be organized to provide a separate Family Practice entrance on the west side on the second floor level,sharing the adjacent parking lot with Mental Health and the Skilled Nursing Facilities. The Outpatient Clinic entrance is on the first floor level. Mental Health Building o The Mental Health programs are contained in a three-story structure. o Because of the grade changes, the first floor of the Mental Health Building is located on and connected to the second floor level of the core hospital. A Crisis Unit, support functions and the main Mental Health Building entrance is located on this first level. o Two Mental Health Nursing Units are located on the second level of this building, and an additional Nursing Unit is located on the third level (fourth level of the hospital). FUTURE PLAN Both the building and the site organization have been given careful consideration relating to the future expansion of the hospital. Those primary hospital departments which are likely to experience the greatest amount of change or growth are located on the lower floor levels. The primary expansion for the core hospital is to the north. This expansion zone will allow for expansion of radiology and emergency,food service, materials management,and surgery,as required. Above this base expansion additional Nursing Unit Floors can be added as required. The Outpatient/Family Practice Building is located to allow future expansion to the south into the adjacent parking lot. If,over time, parking areas are lost to building expansion, consideration will need to be given to parking structures at that time. A proposed location for a future parking structure is identified on the recommended site development plan. 111.100 '�' FACILITIES MASTER PLAN _ DEVELOPMENT RECOMMENDATIONS I I I I - I ,.a MENTAL HEALTH'-� ABOVE L� r-----J II I ADMIT REGIST. MEDICAL RECORDS ELIGIBILITY-] I I VOLUNT. UR/RISK MGMT. II I OUTPATIENT RADIOLOGY �flBBY " OUTPATIENTS— .. ,. VISITORS —� CHAPLAIN i 3 EMERG ADMIN. a� EMERGENCY SYMPTOM L SECURITY CONTROL SOC. SERVICE O O ELEVATOR CORE RECOMMENDED FIRST FLOOR PLAN SCALE 0 25 50 100 111.101 l MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS BUILDING ABOVE i I 1 I I CRISIS UNIT { F I I i MENTAL HEALTH MENTAL HEALTH FIRST FLOOR ENV1RO BIOMED FAMILY PRACTICE SERVICES ELEC. SERVICE ' FAMILY CSR/ PRACTICE STORES PHARMACY LAB FOOD SERVICE EDUCATION & TRAINING LIBRARY MEDICAL DINING DECK EDUCATION O 0 ELEVATOR CORE RECOMMENDED SECOND FLOOR PLAN SCALE 0 25 50 100 111.102 ., ...« ..-;.,, �� .i`�'.S-T{..w..:�fi.t`•rr2�?�`'.s�; itk'S;s Y„F'4.tt} `+�n ±�{�;..�,.'twr'r.:ss,' MERR[THEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS jI■ I�l��� ���YI�YI� Z I .i 7 20 BEDS 20 BEDS { I MENTAL HEALTH SECOND FLOOR 3 CARDIO PULMONARY ROOF SURGERY CRITICAL CARE CRITICAL CARE 8 BEDS COURT 8 BEDS 1 O ELEVATOR CORE k i RECOMMENDED THIRD FLOOR PLAN SCALE 0 25 50 100 111.103 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS 18 BEDS ROOF MENTAL HEALTH THIRD FLOOR MEDICAL/SURGICAL ROOF 25 BEDS 25 BEDS 25 BEDS 25 BEDS O 0 ELEVATOR CORE RECOMMENDED FOURTH FLOOR PLAN SCALE 0 25 50 100 II1.104 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS i ROOF REHABILITATION 10 BEDS J -t ROOF REHAB. THERAPY GERO—PSYCH DETENTION 12 BEDS 14 BEDS � I LJf O rs O ELEVATOR CORE RECOMMENDED FIFTH FLOOR PLAN SCALE 0 25 50 100 111.105 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN DEVELOPMENT RECOMMENDATIONS ROOF ROOF LABOR/DEL. PERINATAL Q 17 BEDS 0 O ELEVATOR CORE RECOMMENDED SIXTH FLOOR PLAN SCALE 0 25 50 100 111.106 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN IMPLEMENTATION AND PROJECT SCHEDULE This section of the report presents how the recommended plan can be implemented. It identifies the various construction phases and assumes a time table for implementation. Project Implementation Strategy The proposed location for the new core hospital is in the area currently occupied by the J & M Wards. These wards house in-patient Psychiatric (Mental Health) and Family Practice, respectively. Before starting the construction of the new core hospital,there are a number of preliminary steps that need to occur. The- fdVIt Ift- d4 fac_il,i,60,J�6 Ap ceupantsof,,-W--Watd.'�'tffgVf-*- ldd%tedsta-jtemp ary Ultimately, Family faciliti'eg"de'pendin'g'bn,-"tft" h'�ti.-'c'o�ffif-guration Practice will be relocated to a new building and M Ward demolished. Phase I This phase requires the construction of new in-patient Mental Health Facilities, and a new Central Plant/Maintenance Building. Before either of these can occur,demolition of existing buildings and relocation of existing mobile office units need to be accomplished. Specifically, thewa .A@LgtL Ward will be demolished,and the south vyjr- =To"Mard may need to be demolished. The existing mobile office buildings to the north of L Ward will need to be relocated. This new Mental Health Building could be constructed in two increments. The first increment would occur to the east of the I Ward. On completion,the occupants of I Ward would move into the new Mental Health first increment. I Ward would then be demolished, and the second increment of construction for Mental Health would be completed. Patients from H Ward and from J Ward would then be relocated to the completed new Mental Health Building, allowing the demolition those two buildings. A new parking area and vehicular entrance to Mental Health will be created on the south side of this new facility. The Central Plant and Maintenance Building should be completed and operational before the first increment of the Mental Health Building is occupied. This construction will require the removal of an existing temporary building. Phase IIA This phase involves construction of the new replacement core hospital. This phase assumes it will be constructed in a singular increment of construction. Other alternatives are available to replace the hospital over time in smaller increments of construction. This would require retention and modifications to some existing buildings and would lengthen the time frame to ultimately replace the existing hospital. On completion,the existing hospital will be vacated and those occupants moved to the new facilities. At the end of this phase of construction, the majority of the existing hospital buildings can be demolished. Space will need to be maintained for the temporary use by Outpatient Clinic areas and Family Practice. 111.107 MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN IMPLEMENTATION AND PROJECT SCHEDULE Phase IIB The third phase involves construction of a new Outpatient and Family Practice Building on the south side of the core hospital. Development Schedule The following description and accompanying schedule outline the major components of the recommended plan and delineate a time frame for implementing the phased construction program. The schedule assumes a conventional design, bid and construction process. Other design and construction scheduling approaches are available that could accelerate these activities and alter the overall time frame for some of these projects. These should be examined for potential time savings. For this early analysis, however, it is appropriate to use the more conservative, conventional approach. The schedule indicates overall development time frames for the two primary construction phases and assumes a continuous process. For each of the construction phases, three activities are identified: Design and Documentation Review and Bidding Construction. Design and Documentation Design activities include three separate steps: 1. Schematic Design 2. Design Development 3. Construction Documentation During each of these steps, construction cost estimates should be undertaken, yielding increasingly accurate estimates of construction costs. Following completion of the construction documents, bidding can occur and the contract price established. 111.108 .. ....; .._. •ar:...r r--_.-:ni.:.n-w:.h^.•srrv..-...-..ct'+,c?rr:..;.t:n(`'O.�i.r,;...-..+.`7�....-:•:`:TS:.^•.Y^.., ... "R�:on`'�+.. MERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN IMPLEMENTATION AND PROJECT SCHEDULE Review and Bidding Following completion of construction documentation for hospital projects, reviews with approving agencies (e.g. State Fire Marshal, Office of the State Architect, Office of Statewide Health Planning and Development) can be initiated. This time period is very difficult to estimate due to the variables of agency work load at a future date. The schedule allows for a six-month agency .. review and approval period, plus three months for bidding and contractor selection. Construction Construction refers to the actual building of the new replacement hospital, as well as site development work(i.e. new roads, parking lots, etc.). i .:t 111.109 �litiltSi'i' LU PAERRITHEW MEMORIAL HOSPITAL FACILITIES MASTER PLAN IMPLEMENTATION AND PROJECT SCHEDULE 1989 1990 1991 ! 1992 1983 1 1994 I P • DECISION TO PROCEED) 1. MENTAL HEALTH& CENTRAL PLANT i . Design&DocumenUdion ! I � ! I Approvals&Bidding ► Construction 2 HOSPITAL&OUTPATIENT ! ! Design&Documeration Approvals&Bidding ! ' Construction ASSUMED PROJECT DEVELOPMENT SCHEDULE 111.110 .. .. .......v.r C'5....r• r. rc... - nr.!c..n .. ...... rtMtc - i'rnn' {.. .r^}!!ei!<?f`;^'r.`C'.C:K?41•`.C'CoS^c..•y',r+w..±v .^^•.-'„..t•« ..«.., .. .. t.^. .'s S ^'3^.�ri.ir✓sF IlVe FINANCLA.L PLANNING 4 I t f: 4 i FINANCIAL PLANNING TABLE OF CONTENTS P IV. FINANCIAL PLANNING 1. Background IV.6 2. Basis for the Projection IV.7 3. Summary of Significant Accounting Policies IV.7 4. Financing Plan IV.8 1 5. Projected Facilities Utilization IV.11 1 6. Patient Service Revenue IV.15 7. Deductions from Revenue IV.15 8. Other Operating Revenues IV.18 9. Operating Expenses Excluding Depreciation, Amortization and Interest IV.19 10. Property, Plant and Equipment, Depreciation and Amortization Expense IV.20 11. Hospital Bonds and Required Funds IV.21 12. Other Long-Term Obligations IV.23 y 13. Nonoperating Revenues IV.23 O Qr�, A MEMBER OF ARTHUR YOUNG INTERNATIONAL • 2175 North California Blvd. Arthur Young Walnut Creek, California 94596 Telephone: (415) 977-2900 Board of Supervisors Contra Costa County At your request, we have performed certain agreed-upon procedures, as enumerated below, with respect to the accompanying projected statements of revenue and expenses of Merrithew Memorial Hospital (the Hospital) for the periods ending June 30, 1989 through 1996. These projections assume two options available to the County: • To continue operating the Hospital as before with no major replacement To replace the facility in conjunction with major programmatic and product focus, development and promotion. These options are further described in Note 2. These procedures, which were specified by the Health Services Department of Contra Costa County, were performed solely to assist you in connection with the proposed decision regarding building a replacement hospital. We make no representations as to the sufficiency of these procedures for your purposes. It is understood that this report is solely for your information and should not be used by those who did not participate in determining the procedures. The agreed-upon procedures that we performed were as follows: a. We assisted the management of the Health Services Department in assembling the prospective financial information. b. We reviewed the reasonableness of management's assumptions used in the preparation of the projection and provided our comments thereon. c. We tested the projection for mathematical accuracy. Because the procedures described above do not constitute an examination of prospective financial statements in accordance with standards established by the AICPA, we do not express an opinion on whether the underlying assumptions of the prospective financial information provide a reasonable basis for the presentation, given the two options for the County, as described above and in Note 2. ado Arthur Young In connection with the procedures referred to above, no matters came to our attention that caused us to believe that the format of the projection should be modified or that the projection is mathematically inaccurate, based on the assumptions as described in Note 2. Had we performed additional procedures or had we made an examination of the projections in accordance with standards established by the AICPA, matters might have come to our attention that would have been reported to you. Furthermore, even if these assumptions occur, there will usually be differences between the projected and actual results, because events and circumstances frequently do not occur as expected, and those differences may be material. We have no responsibility to update this report for events and circumstances occurring after the date of this report. _, Ani+...,. v.,.� � C�+�.�a►-� November 14, 1988 ..l J J _1 IV.2 �IN �N• INH M O••NNN �• F V d N v twI .. ae«MI Opppppp s,••NiNNAM/�F�N c .1 $�� INjI "a i P I••'1 N .II.N N III OONN• S v N N M • twwwl v ' 4�I . � .ON S � O,HN•• — I� y N • y MMM N v W r�.I SII — I� y� g Y I� I�.O O .• O � W ��� : � I�HHi iK•�:�Isyy �al iJ�e�NS.��d y�e���o�spH�•1: :�nyy �S �8�d�:I17H��:�aHp:d :eN�r �I .0 ■•• H�pII:I.O��:•O� ��A�P��+�IL�N:O O •�^.M:Iv.� :.~j �..1 34 WZ Q. ••�N •S S � ISN—•• — $ y v • r it at •w O fi � O• s I}p� �pH Ip. .I•H �qp �pH N 8 /� I�Hp IH IO :.p•A♦ .1 • .: •In�:00• T�M �MFPNA:-O O OP N:N: v IPIII � «�RFAWs««s « is ��� '� « « � � 4-J •iN •O� S A �M^•M A v h • � � 4i I W.N'�.�•N '•f Y St�^nx i O� ' I ���C.'�No•� 5 — +> -� s w � o /• M • w • M a • "' v C '•� IH Ip1�O M O P�I N 8 .spypp �M1I 8 Myp� .ep spy �•pp .. `w . 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Y.,: ♦op AA �_yB Ap S/�p8 •p. 8 » yp� �.pp : 10 :•.P:A �Or1M� �MNA•OP .O i OP : • :rM :1+1 �f O MN RN on '� A•�N.iM �� ' O .fes v O• v M 7 IL `• v a v � a-'VOiaoE'a 29EH HH •v x gas p • � •.ON•r PI AnPaN In62 v M •y' X pryA•��yOMNpi yI tlMi:N •n• L OBO�NPIII E a ` • H 'ON r N •0-0-04N N v p •f = .. ey r ey 8 .p • •P : NO.PI .O�: s �N.Y100N M.pp�p OMNIA IO :O A O P :IMInn:M:.. •n '• L f 11ppyy ''•^ ' M�IAIIMN In�nN^pN. :r P H�� :N:•• :A •A �• • HPI :•O� :N ••�dN N.O If M•ON :O N ♦� .0%.42C ` Mo YAf.C. O• N O.I—IIN 4a. • �1 .1 N O pp.. p .p.ppp..yryMrylI SS�.InrtINpN A IynI S/pIIII •h � O IynI�O :1*� .$ H�NPNn^nPYNIN •O O H�� :N 'IY : • Y 'ONMI .VN:N �p .I♦NPI O •� .n :�V 1�1 ^p P .I.A. A• 1O 'O MI Pf N A y p: IL E-1 - ep �i{UIU $""�'�` Cpl �rI N n �^ .I MN :N.O .Y •���o'�•nNQ ANS •p '^;y� :�An :ri ~ L on nIK .1,0: : POf !V •IR:II i( v Y r ... CL � " g preILIttills sap s =mc g I4A k k (k $ \ of $ f k m : cq '§ ( kk;v ° ) - � , . F °2 °© § c! . '§ } § 8 k!§ ° k CL - I �2 �o °k;§ °E § I 2 $ ( )r4 , F., v { ® u/|00. OcD em$ / C � 2L -& }k _ _ o ' 0 Co o . . 'CL _ 42 CDC a 0 C. _ $ f . g ■ : ■ i § i § ■ ,�§ ! I 7 j $ �� r ■ � | �.■� - ■ ! 2 @ ' § \� 05 ) $AL ! c E IV. 5 MERRI'ITIEW MEMORIAL HOSPITAL SUMMARY OF SIGNIFICANT ASSUMPTIONS UNDERLYING THE PROJECTED FINANCIAL STATEMENTS YEARS ENDING JUNE 30, 1989-1996 1. BACKGROUND Merrithew Memorial Hospital (MMH) is owned and operated by Contra Costa County (the County). It is a full-service inpatient hospital with 191 beds, and also provides mental health, geriatric, and outpatient services. The Hospital campus currently contains a number of separate component facilities, as well as a main hospital complex composed of several wings. The wings are located on different levels of a hillside, and are connected by a roof structure and a partially enclosed corridor. The oldest portions of the hospital complex date back to 1914, and the major portions of the main hospital were constructed in the 1940s and 1950s. The buildings and systems are almost all out of date and at the end of or beyond their projected useful lives. They are still in service through the continued maintenance work of the County and General Services Department. The:.facilities yg�e.erally'do not meet the..standards:_of:.current health;safety�xliu lding�a-iid-erigineermg:;codes,: In short, the.Hospital:-has1 been charactenzed by both°suMorters,,tncl�detractors>as antiquated and beyond,repair. In Contra Costa County, the burden of uncompensated care borne by Merrithew Memorial Hospital is nearly 60% of total uncompensated charges in the County. In addition, the population served by the Hospital brings a variety of health problems associated with marginal economic status, and the inefficient physical facilities have presented additional challenges to County management. The Board of Supervisors approved, in concept, the recommendation of the Health Services Director to replace the facility with asir, rnoderlYty, but requested verification of the feasibility of such a replacement project. The County then engaged Arthur Young to determine the feasibility of constructing a replacement to the Hospital. Feasibility was to be evaluated in terms of availability of funding, alternative funding sources, and impact on the County's General Fund contribution to the Health Services Department. In addition, Arthur Young was to project service volumes, recommend optimal program configuration and size, estimate operational and staffing costs, develop a preliminary functional and space program, and estimate project costs. In addition, the County requested a special focus on evaluation of additional programs to provide the full continuum of care for geriatric patients, perhaps under the umbrella of a Geriatrics Institute. IV.6 w� .. .. .. '...-11'!,'i'"•'.:?n� hj+y�o.7+:ti^. ...].ZA.w-...]•� :G... '_'.. _ - .i ._ 2. BASIS FOR THE PROJECTION The financial projection presents Contra Costa County management's estimate of the results of operations for the projection period, assuming the County pursues one of the options described below. Accordingly, the projection reflects management's judgment as of July 19, 1988, based on present circumstances, of the set of conditions and its course of action. The assumptions presented herein, upon which the projected financial statements are based, are those which management believes are significant to the projection or are key factors upon which the projected financial results of the County will depend. It is usually the case that one or more of the assumptions do not materialize because events and circumstances do not occur as expected and unanticipated events and circumstances may occur. Therefore, the actual results achieved during the projection period probably will vary from the projected results, and the variations may be material. Option I: Base Case (Status Quo): This projection assumes that the County will continue to operate its existing facility and no major replacement will be attempted. OptiomI:assmms� a<,continuing:Bass of.-,marlet;s a <� KMed az'e>� di''. al. population seinnts;'resulting in services being provided almost exclusively to indigents. Option II: Replacement Hospital: This projection assumes that the County will i modify its geriatrics, obstetrics and AIDS programs and build a 227 bed replacement facility in Martinez. It is assumed that MMM will implement the Geriatrics, Obstetrics/ Women's Health and AIDS programs in 1989. The construction project is divided into the following two phases: • Mental Health and Central Plant/Maintenance Building • Core Hospital and Outpatient/Family Practice Building These two phases will become fully operational in November 1991 and May 1994, respectively. Option II assumes increased market shares in Medicare and Medi- Cal, and increased Health Plan enrollment while allowing continued care for indigents. 3. SUADUR.Y OF SIGNIFICANT ACCOUNTING POLICIES A summary of significant accounting policies applied in the preparation and presentation of the accompanying projected financial statements are presented below. IV.7 Patient Service Revenue - Patient service revenue is recorded on the accrual basis of accounting in the period in which services are provided at established rates, whether or not collection in full is anticipated. Contractual and charitable allowances, the results of other arrangements for providing services at less than established rates and the provision for uncollectible accounts are reported as deductions from patient revenue. Contractual adjustments include differences between established billing rates and amounts estimated by management as reimbursable under various cost reimbursement formulas on contracts in effect. Normal estimation differences between final settlements and amounts accrued in previous years are reported as current year contractual adjustments. Interest Income - Interest income earned on invested funds is reflected as nonoperating revenues. Property, Plant and Equipment - Property, plant and equipment are recorded at cost, less accumulated depreciation. Donated assets are recorded at fair market value at the date of the contribution and are subsequently considered as being on the cost basis. Depreciation is computed using the straight-line method based on the estimated useful lives of the various classes of assets. Lease costs which have been capitalized are amortized over the life of the lease. Lease amortization is included in depreciation expense. Interest Expense - Interest expense applicable to construction is capitalized as part of construction-in-progress. The amount of interest capitalized is the interest cost of the restricted tax-exempt borrowings less any interest earned on temporary investment of the proceeds of those borrowings during the period of construction. 4. FINANCING PLAN The County plans to utilize the proceeds of the proposed financing plan to purchase capital equipment and construct a replacement facility. It is anticipated that the two construction phases of the building project will be completed by November 1991 and May 1994, respectively(see Note 2). IV.8 The estimated sources and uses of funds for the project are summarized in the table below and presented in detail in Figure IV.1 on the following page. MERRITHEW MEMORIAL HOSPITAL SOURCES AND USES OF FUNDS (in thousands of dollars) Sources of Funds Bond Proceeds $123,833 Interest earnings on available project funds (a) 26,831 Hospital Contribution (b) 1,200 Total Sources $151,864 Uses of Funds Construction W $69,733 Capital equipment expenditures (c) 16,302 Professional fees , 9,066 Funded interest (d) 41,289 Debt issuance costs (e) 3,500 Bond Reserve Fund M 11,974 $151,864 (a) Assumes an annual investment rate of 8.25 percent for the balances in the Construction Fund, the Capitalized Interest Fund and the Bond Reserve Fund during the period of construction. (b) Assumes the Hospital will contribute this amount to the project. W Construction, equipment and other costs have been estimated by management and construction consultants. (d) Interest on the portion of the bond proceeds allocable to the construction and renovation projects for the period from 1990 to 1996. (e) Includes legal fees, consulting fees, printing and other miscellaneous expenses. M Based on the maximum annual debt service for both principal and interest payments assuming an annual interest rate of 8.35 percent. IV.9 FIGURE IV.1 ; MERRITHEW MEMORIA U-IIOSPITAL PROJECT COSTS- ,, (000s) Estimated Total Construction Mental Health $ 7,689 Central Plant 2,729 Hospital 55,073 Outpatient 4,245 Total Construction*_ 69,733 Project Related Mental Health 999 Central Plant 355 Hospital 7,160 Outpatient 552 Total Project Related 9,066 Equipment _ Mental Health t: Central Plant0 Hospital 14,870 Y Outpatient 509 Total Equipment jam'-_,16;302 Total Mental Health 9,611 Central Plant 3,081 Hospital 77,103 Outpatient 5,306 Total $95,101 *Includes scope and desicontingency of 15% IV.10 ...•......)v.+Y:t Ji,.^_-..�}'+34 .!.:�T�_ .iF.`Yv `OC.'47CC v. K\. •O)?i'+:y�ti� .. _ .. .. -'{ .. +moi'?._..�3?`h^�`•-_..._._v-.._'•.=w__�=.SGC:PI,"_s�OCtcr,, r.w.v.....+.- •..Y.'s Sri^.x 5. PROJECTED FACIES UTILIZATION Trend analyses were performed based on three-year actual historical utilization during years 1986, 1987 and annualized 1988. The patient day projections for the years ending June 30, 1989 throug 1996 are based upon 8 month annualized 1988 data. More specifically, the analyses performed and factors considered include the following: 0 Identification of the geographic service area from which MMH has historically drawn patient admissions 0 Review of published demographic and socioeconomic statistics for MMH's service area and the entire County, including historic and projected population growth and age trends 0 An analysis of historical market share trends 0 An analysis of the impact of increased patient days for geriatric, obstetric and AIDS services. Patient Origin and Service Area An analysis of patient admissions by zip code of patient residence for the calendar years 1984, 1985 and 1986 was the basis for defining MMH's primary and secondary service areas. The primary service area for the Hospital consists of Martinez and Pittsburg. The primary service area accounted for 30.1 percent of total admissions in 1985. The three secondary service areas for the Hospital include: 0 Concord - Concord and Walnut Creek 0 Richmond - Richmond, San Pablo and Rodeo * Antioch - Antioch, Brentwood and Oakley In 1985, the Concord, Richmond and Antioch secondary service areas accounted for 23.2 , 21.7 and 10.7 percent of total admissions, respectively. The primary and secondary service areas for the Hospital are assumed to remain constant on an overall basis for the projection period. Demographic Characteristics - In order to assess the demographic factors that influence health care utilization and compensation, an analysis was made of key socioeconomic and demographic statistics for the service area population and for the entire County. Historical data is based on the 1980 U.S. Census, with population projections developed by National Planning Data Corporation, IV.11 The table below presents comparative population statistics for MMH's primary and secondary service areas, and for the entire County. MERRITHEW MEMORIAL HOSPITAL COMPARATIVE POPULATION STATISTICS 1980-1996 Martinez/ Pittsburg Richmond Antioch Concord Primary Secondary Secondary Secondary Contra ;- Service Service Service Service Costa i Area Area Area Area County 1980 Population 90,691 104,657 58,375 159,887 656,380 1980 Percent Age (Years) 0-14 24.48% 23.57% 25.96% 20.77% 21.94% 15-44 (Women) 24.81 24.49 24.60 25.75 24.32 65-74 4.95 6:63 5.26 4.91 5.83 75+ 2.51 3.42 2.94 3.12 3.44 Source: National Planning Data Corporation The overall age distribution of the primary and secondary service areas is fairly consistent with that of Contra Costa County. The historical and projected annual population growth rates for the entire County are approximately 1.6 percent for 1980 through 1985, 1.3 percent for 1985 through 1991, and 1.1 percent for 1991 through 1996. Market Share Trends - The Hospital's historical market share of total patient admissions for the County was approximately 14 percent during 1985 and 1986. Due to deterioration of the facility, the County-wide market share for the Hospital for Option I is projected to decrease to approximately 13 percent in 1990. However, for Option II, assuming the implementation of the Geriatrics, Obstetrics/Women's Health and AIDS programs, the market share for the Hospital is projected to increase approximately 4 percent annually as the marketing force of these programs gains momentum. Competitive Environment - Six competitive acute care hospitals operate in MMH's primary and secondary service areas. The table below presents key statistics for these institutions. IV.12 MERRITHEW MEMORIAL HOSPITAL PROFILE OF COMPETITORS Fiscal Year Ending 1986 1 Percent Licensed Percent Mkt Facility Ownership Beds Occupancy Share + Merrithew Memorial County 311* 51.9% ** 14.12% Brookside County 246 41.6 13.88 j Delta Memorial Non-Profit 53 63.8 5.02 John Muir Memorial Non-Profit 262 68.1 19.67 Los Medanos Community District 78 64.9 6.85 ` Doctors-Pinole Investor 137 62.4 9.40 Mt. Diablo District 303 60.7 23.31 J _ * 213 available beds. ( ** Based on Available beds. + Based on total patient days for the County. Source: Hospital Council of Northern California, Discharge Study, 1986. As seen from the table, NIMH maintains 14 percent of the market share of total patient days relative to the six hospitals it considers its main competitors, ranking third to Mt. Diablo and John Muir Memorial which have 23 percent and 20 percent of the market share, respectively. Patient Service Mix - Under Option I, the occupancy rates for the Hospital are projected to increase to approximately 72 percent for acute care and 100 ! percent for psychiatric care in 1996. Under Option H, the occupancy rates are projected to increase to approximately 80 percent for acute care and decrease to 85 percent for psychiatric care in 1996 due to the increase in bed capacity in the new facility. The average daily census for psychiatric care will increase from 40 patients per day in the base case to 49 patients per day in the new hospital. .J IV.13 The table below presents historical and projected occupancy rates for Option II for Merrithew Memorial Hospital. MERRITHEW MEMORIAL HOSPITAL HISTORICAL AND PROJECTED OCCUPANCY RATES 1986-1996 Acute Psych Years ending Licensed Licensed Acute Psych June 30, Beds Beds Occupancy Occupancy Historical 1986 173 40 44.32% 83.86% 1987 173 40 45.24 84.27 1988 (annualized) 151 40 60.58 86.73 Projected 1989 151 40 60.20 100.00 1990 151 40 67.30 100.00 1991 151 40 72.03 100.00 1992 151 52 76.63 76.92 1993 151 58 78.91 76.36 1994 154 58 79.44 80.07 1995 169 58 76.24 82.12 1996 169 58 80.11 85.31 The acute occupancy increase in 1988 was due to the increase in Medicare and Medi-Cal patients at the Hospital. In addition, obstetric services increased significantly during the year. The occupancy increases during the projection period are primarily due to the impact of population growth on medical/surgical services, and implementation of the new geriatrics, obstetrics and AIDS programs. It is assumed that Merrithew Memorial Hospital will maintain a constant market share during the projection period. Outpatient Activity - For Option II, MMH's outpatient activity is assumed to increase 4 percent annually during 1989 through 1994 and 6 percent annually ' during 1995 and 1996. IV.14 6. PATIENT SERVICE REVENUE Gross inpatient and outpatient revenues are projected based on the projected - volume of patient services, the 1988 rate structure and the annual rate increases which pass through assumed annual inflationary cost increases. The annual rate increase for acute care and psychiatric services at Merrithew Memorial Hospital for Option I is projected to be 2 percent annually between 1990 and 1996. For Option II, the annual rate increase is projected to be 4 percent annually between 1989 and 1996. 7. DEDUCTIONS FROM REVENUE Deductions from revenue represent estimated contractual allowances, charity care, losses from uncollectible accounts and HMO/PPO discounts. In order to estimate these revenue deductions, projected patient days for each year of the projection period are classified by payor source. This classification is based on the Hospital's current experience adjusted for changes anticipated during the projection period, including the growth of HMOs and PPOs in California. To show the impact of these anticipated changes, the estimated percentage of patient days by payor source for 1988 and 1996 for Option II are compared in the table below. Merrithew Memorial Hospital Years ending June 30, 1988 1996 Acute Psych Acute Psych i Medicare 29.82% 32.46% 37.32% 45.81% Medi-Cal 34.53 44.21 31.06 35.23 Private Insurance 1.92 2.58 2.66 2.15 Contra Costa Health Plan 25.54 3.81 23.30 3.32 Private Pay 6.42 1.41 4.63 1.12 Other 1.77 15.52 1.03 12.37 •� 100.00% 100.00% 100.00% 100.00% Allowances result primarily from anticipated contractual services to patients insured by Medicare, Medi-Cal and other contracts. These allowances represent the difference between billed charges and the amount received or receivable under ' the provisions of the third-party payment programs. As a result of the Social Security Amendments of 1983 (the Act), the Medicare program provides for a prospective payment system for inpatient hospital services based on Diagnosis Related Groups (DRGs). This payment system is applicable to hospital fiscal years beginning on or after October 1, 1983 and is being phased in over a five year transition period. IV.15 Hospital inpatient services are paid at a predetermined, specific rate for each discharge on a prospective payment system. The Act provides for a transition period during which a declining portion of the total prospective payment will be based on a hospital's historical costs in a given base year, and an increasing -- portion will be based on regional and national rates per discharge. i The current schedule for Merrithew Memorial Hospital as provided by the amended Act is as follows: Federal Portion Hospital-specific Period Regional National portion 10/01/86- 09/30/87 37.50% 37.50% 25.00% 10/01/87- 0.00% 100.00% 0.00% The Act, in its present form, provided for annual increases of the various portions of prospective payment per discharge according to increases in the "market basket of hospital goods" as computed by the HCFA (the DRI Health Care Cost Index, computed for HCFA under contract) less 2 percent. The projection has assumed that for both Options, Medicare PPS blended rates per discharge for the Hospital will increase by 1 percent in 1989; 1.5 percent in 1990 and 1991; 2 percent in 1992 and 1993; 2.5 percent in 1994 and 1995; and 3 percent in 1996. The Medicare PPS blended rates per discharge for the Hospital are presented in the table below. MERRITHEW MEMORIAL HOSPITAL MEDICARE PPS BLENDED RATES 1988-1996 1988 $4,581.67 1989 4,978.67 1990 5,053.35 1991 5,129.15 1992 5,231.73 1993 5,336.37 1994 5,469.77 1995 5,606.52 1996 5,774.71 Merrithew Memorial Hospital's case mix index, for the projection period, which reflec the intensity of service rendered to Medicare patients, is 1.0708. IV.16 The Medicare payment per discharge (the Medicare blended rate multiplied by the Hospital's case mix index) for MMH during the projection period is presented below: MERRITHEW MEMORIAL HOSPITAL MEDICARE PAYMENT PER DISCHARGE 1988-1996 1988 $4,906.05 1989 5,331.16 1990 5,411.12 1991 5,492.29 1992 5,602.14 1993 5,714.18 1994 5,857.03 1995 6,003.46 1996 6,183.56 Most outpatient services provided to Medicare patients will continue to be reimbursed based upon reasonable cost according to the Act. Reimbursement a for Medicare outpatient services was projected on a cost to charge relationship throughout the projection period. The cost to charge relationship declines by approximately 1 percent annually during the projection period due to the fact J that charges are increasing at a faster rate than expenses. ? In 1985, Congress passed the Balanced Budget and Emergency Deficit Control Act (Gramm-Rudman) in an attempt to eliminate the Federal deficit by 1990 through the control of the Federal budgeting process and the gradual reduction of the deficit by specific amounts. Gramm-Rudman allows for a reduction in payment rates of up to 1 percent in fiscal year 1986, and up to 2 percent for each fiscal year thereafter as part of total spending cuts deemed necessary to balance Federal budgets. On August 20, 1986, the Office of Management and Budget, and the Congressional Budget Office issued a joint resolution reducing Medicare payments for covered services by 2 percent under the initial sequestration report for the 1987 Federal fiscal year as required by Gramm-Rudman. Although the Supreme Court has ruled that the automatic spending limitation mechanism authorized by Gramm-Rudman is unconstitutional, the joint report was issued under a "fallback" provision whereby Congress is required to vote on a resolution setting forth the contents of the report. If the resolution becomes law, the President must follow its terms in issuing a sequestration order. Gramm- Rudman may have the effect of cutting money from certain traditional health care reimbursement programs. The projection does not include any assumption related to the possible impact of Gramm-Rudman. Capital expenditures are generally defined as depreciation, interest on capital borrowings, insurance on capital items and rent of capital assets. HCFA has invoked a reduction in the amount of reimbursement for capital expenditures. r The projection has assumed the 12 percent reduction for Medicare capital reimbursement for 1988 and 15 percent reduction for the remaining eight years ' of the projection period. IV.17 s . .,. .- ... .•c.�.,.- --....�.,..u_,:ti= -------- =---e.•- '',���t'ti::c.�`..•.;.z;c+__•'. .-=`_:.'tti�?.'LLc%ti?t?43f?fir�wor�.tcxw Numerous changes to the final Medicare regulations have been proposed by various Congressional Committees. One of the proposals is to change the method of reimbursing hospitals for capital expenditures from the present cost system to a national average amount per discharge. If these proposals are enacted it could have a significant impact on the amount of Medicare reimbursement. As a result of California Assembly Bill 799, which was passed in June 1982, acute care hospitals have had to negotiate for service contracts with the State of California for Medi-Cal inpatients. The Medi-Cal reimbursement rate is estimated to increase-approximately 3 percent annually from 1989 to 1996. The Contra Costa Health Plan contains four types of enrollees: • Medicare _ • Medi-Cal • Private • Basic Adult Care/MIA Historically, the Health Plan has paid the Hospital at the rate of 66 percent of charges for services provided to Health Plan patients. - For purposes of this project, we have calculated the portion of the premiums collected by the Health Plan which are applicable to services provided by the Hospital and included these amounts in the projections as the premiums collected directly by the ; Hospital. For both options, the hospital-specific portion of the Health Plan premiums is assumed to be 78 percent through the entire projection period. Because increases in the contracts are generally limited to the consumer price index increases, the CCHP premiums have been adjusted by 3 percent, 3 percent and 5 percent annually for Medicare, Medi-Cal and Commercial, respectively during the projection period. The Basic Adult Care patient care is reimbursed by the State and is assumed to remain at the 1988 rates in 1989 through 1993 and increase 4 percent in 1995. It is assumed that the reimbursements will remain at the 1995 rate for 1986. For Option II, based on historical experience, provisions for uncollectible accounts, charity care, CCHP discounts and other allowances are estimated at 30 percent for Commercial and Blue Cross, 83 percent for Self-Pay, and approximately 25 percent for CCHP gross patient revenues for fiscal year 1989. This percentage has been projected to remain constant for all payors except CCHP which is projected to increase to 33 percent in 1996. 8. OTHER OPERATING REVENUES Other operating revenues consist primarily of other medical services and other non-patient charges. These revenues are expected to increase at an average annual rate of 1.7 percent during the projection period for Option I. For Option II, the annual rate of increase is 3.4 percent. IV.18 9. OPERATING EXPENSES EXCLUDING"DEPRECIATION,AMORTIZATION AND INTEREST The most significant operating expense assumptions include salaries and wages and employee benefits, maintenance, depreciation and interest. Salaries and Wages and Employee Benefits - Salaries and wages are projected by applying salary and wage rates to staffing levels required to provide services to meet projected demand. Staffing requirements are expressed in terms of full-time equivalent employees (FTEs) per occupied bed, adjusted for service utilization related to outpatient services. Total projected FTEs are based on fixed/variable staffing relationships applied to projected patient activity. Historical and projected total FTEs and FTEs per adjusted occupied bed are presented for Option II in the table below. MERRITHEW MEMORIAL HOSPITAL HISTORICAL AND PROJECTED FTES 1986-1996 Years ending Total FTEs per Adjusted June 30, FTEs Occupied Bed Historical 1986 685 4.00 1987 710 3.93 1988 713 3.58 Projected 1989 713 3.49 1990 732 3.41 1991 745 . 3.36 1992 . 758 3.31 Y 1993 774 3.26 1994 784 3.23 1995 801 3:18 1996 820 ''"` 3.13':. For both Options, average wage and salary rates are based on 1988 rates and are ! assumed to increase 3.5 percent per year throughout the projection period. 3 IV.19 Employee benefits will approximate 23 percent of salaries and wages for the projection period. Employee benefits include social security taxes, unemployment insurance, workers' compensation, group health insurance, pension plan contributions, and other. Management does not anticipate any new employee benefits during the projection period. Maintenance Costs - For Option I, it is assumed that the Hospital will have to continue substantial repairs to the building, forcing maintenance costs to increase to approximately $1.9 million.in 1996. However, for Option II, maintenance costs are significantly lower. It is assumed that construction of the new facility will allow the Hospital to reduce necessary maintenance on the existing'building. Maintenance costs in 1996 are assumed to be approximately $600,000. Interest - For Option II, due to capitalization of interest and interest on the unexpended bond proceeds during the construction phase of the project, the interest expense is estimated to be approximately $.4 million in 1990 and $1.5 million in 1994. However, at the completion of the project, interest is no longer capitalized and all bond proceeds will be expended; therefore, the interest expense will increase to approximately $9.5 million in 1996. Supplies and Other Operating Expenses - Supplies and other operating expenses are based on future utilization estimates and historical fixed/variable expense patterns for each cost category. It is assumed that inflationary increases for rent will average 6 percent annually during the remainder of the projection period. For utilities, it is assumed that annual inflation increases will be 7.5 percent during the projection period. However, utility expense per new square foot is assumed to decrease from $9.85 in 1994 to $6.35 in 1995 when the Hospital opens, due to a more efficient building. Malpractice insurance expense is projected assuming annual inflation increases of 5 percent for 1989 through 1992; 6 percent for 1993 and 1994; and 8 percent for 1995 and 1996. For Option I, the malpractice inflation rates is assumed to remain constant at 5 percent. Maintenance, "other" fixed and registry expenses are projected to increase 6.1 percent annually in 1989 through 1994 and 8 percent annually in 1995 and 1996. For Option I, the rate of increase remains constant at 6.1 percent. For Option II, fixed and variable professional fees are assumed to increase by 5.5 percent annually from 1989 to 1994 and by 6.5 percent annually in 1995 and 1996. In Option I, the annual rate of increase is assumed to remain constant at 5.5 percent. For both options, supply expense is assumed to increase at an annual rate of 5 percent with management fees increasing at an annual rate of 5.5 percent. 10. PROPERTY,PLANT AND EQUIPMENT,DEPRECIATION AND AMORTIZATION EXPENSE Estimated provisions for depreciation for fiscal years 1989 through 1996 are computed based upon the straight-line method for the Hospital's present and proposed buildings and equipment. IV.20 For Option II, the total estimated depreciable cost of the proposed building project is approximately $.5 million in 1993, approximately $.9 million in 1994 and $3.1 million in 1995 and 1996. The first year of depreciation for the building project is assumed to be fiscal year ending June 30, 1993. Bond issuance costs, including the legal fees, consulting fees, printing and other miscellaneous expenses are estimated at $3,500,000. These costs have been amortized over the life of the bonds on a straight-line basis. 11. HOSPITAL BONDS AND REQUERED FUNDS Contra Costa County plans to finance the proposed project primarily with the ' issuance of a $124 million bond. There are several options available to Contra I Costa County for financing. These include: • Certificates of Participation • General Obligation Bonds • CHFFA County Pool Series A • CHFFA County Pool Series B • County Municipal Lease • Non-Profit Corporation Revenue Bonds • Certificates of Participation - Certificates of participation can be issued by the County on either a competitive or negotiated basis. They can be structured on either a fixed or variable rate basis as a lease and leaseback. Certificates due require an annual appropriation clause in consideration for the use and occupancy of the facility. Issuance of certificates by the County provide the most flexible of alternatives available for the financing of major capital expenditures. Our projections for constructing the replacement facility assume this type of financing. • General Obligation Bonds - These bonds are repaid from ad valorem taxes on assessed real property located within the County. General obligation bonds are one of the least expensive avenues available for the financing of public projects. The costs of issuance are lower and the interest rates are typically between .25 percent and .50 percent lower than comparable revenue bond or certificate issues. These bonds however, can be secured by fixed rate debt only. J • CHFFA County Pool Series A - The 1986 Series A bonds were issued by the CHFFA with proceeds from their sale used to fund a bond reserve fund. Project fund proceeds are to be used for financing the acquisition, construction, and installation of health facilities. These bonds are structured r on a variable rate basis and must be secured by a letter of credit. In addition, the annual bank credit fee is payable at a maximum rate of.6 percent per annum of the lease amount. IV.21 ,,..- .. ...._-_ ,.-.r,;._....__:.t•u.c_�,.._ wz;; ..z �«�.a .:.x. T... .. _.:ate. _ • CHFFA County Pool Series B - These bonds are identical to the Series A bonds with the exception of the following items: - Letter of credit is issued by a different corporation. - Bonds carry a variable rate until August 1, 1989, after which the interest rate will be fined if the fixed rates fall at or below 7.50 percent. - An additional one-time 1.5 percent discount is set aside in the event the bonds are converted to a fixed rate. - The annual bank credit fee is payable at a maximum rate of.5 percent per annum of the lease amount. • County Municipal Lease - Municipal leases are generally used for the financing of assets having a useful life of ten years or less. These leases are structured to transfer title to the lessee at the outset or at the lease termination date. Municipal leases can be structured on a fixed or variable basis and are usually used for short term financing of equipment. • Non-Profit Corporation Revenue Bonds - These bonds are issued by a non- profit corporation which is established by the County. They can be secured by revenues of the Hospital enterprises fund or the County's general fund and can be issued as variable or fixed rate debt. This financing mechanism is very similar in design and flexibility as can be achieved through the issuance of Certificates of Participation by the County. Hospital Bonds The bonds are expected to have the following debt service requirements: • An average annual bond interest rate of 8.35 percent • The funds are assumed to be available for construction and reimbursement for capital expenditures during fiscal year ending June 30, 1990 • The average life of the bonds is 30 years. Principal and interest was assumed to be paid on a serial basis. Summarized below are the interest and principal payments during the projection period. Years ending Interest Principal June 30, Payments Payments 1990 1,566,233 0 1991 2,526,912 0 1992 41409,400 0 1993 7,059,084 0 1994 9,462,086 0 1995 10,371,022 1,603,336 1996 10,236,743 1,737,615 IV.22 It is assumed that the following trustee=held funds will be established upon receipt of the bond proceeds: • Construction Fund - All funds to be expended to pay for capital expenditures shall be deposited into the Construction Fund • Capitalized Interest Account - Funds shall be deposited which, together with l interest earned thereon, will be sufficient to make two years of interest payments on the bonds related to construction during the period of construction 12, OTHER LONG-TERM OBLIGATIONS As of June 30, 1988, Merrithew Memorial Hospital has no long-term debt obligations. f 13. NONOPERATING REVENUES Projected nonoperating revenue consists primarily of interest income earned on both bond related funds, board designated funds, unrestricted fund investments and income from partnership investments. Interest income on the bond related funds was calculated using a rate of return of 8.25 percent. IV.23 V. RE C OMMENDATI ONS F ` V. RECOADIENDATIONS i The strategic, architectural and financial planning phases of this study resulted in a series of recommendations which ultimately support the County's decision to build a replacement hospital. We recommend that the County's most appropriate future role include the following components. The County should: 3 Continue meeting the growing needs of Medi-Cal and other economic groups for physician and acute medical services • Expand and enhance services to geriatric populations in specialized areas, beginning with the existing strong medical/psychiatric program • Use the County's strong presence in the obstetrics market to expand and enhance the continuum of services to women and their families i • Respond to unmet community needs which the private health system cannot or will not provide for, such as AIDS Enhance physician practice and clinics to compensate for declining private sector availability while also supporting the County Health Plan • In conjunction with the above programmatic strategies, seek appropriate regional cooperative opportunities to use Merrithew Memorial Hospital resources to meet health care needs. J The recommended configuration for the replacement hospital is a 227 bed, six story building with adjoining outpatient/family practice and mental health facilities. The development recommendations include the following: The hospital will be accessed directly from city streets with a separate access point for Emergency, Mental Health and Family Practice A major new parking lot is proposed for development with access to the main hospital. Separate parking should also be developed to serve the Emergency Room, Mental Health, and Family Practice. i • The first floor of the main hospital will contain the Radiology and Emergency Room, Registration, Admissions, and Medical Records V.1 • The second floor of the main hospital will contain primary service departments of CSR, General Stores,Food Service, Laboratory, and Pharmacy • The third floor will contain Surgery, Critical Care and Cardiopulmonary units • The fourth floor will be the Medical-Surgical Nursing Unit with four nursing units clustered about the central core of service and patient elevators i • The fifth floor will contain the Rehabilitation Therapy, Rehabilitation Nursing unit, Gero-Psychiatric Nursing unit and Detention Nursing units. • Only half of the sixth floor is planned for development and contains a seventeen bed Perinatal unit, New Born Nursery and Labor/Delivery Suite. Both the building and the site organization have been given careful consideration relating to the future expansion of the hospital. Those primary hospital departments which are likely to experience the greatest amount of change or growth are located on the lower floor levels. The primary expansion area for the core hospital is to the north. This expansion area will allow for expansion of radiology and emergency, food service, materials management, and surgery, as required. Above this base expansion additional nursing unit floors can be added as required. The Outpatient/Family Practice Building is located to allow future expansion to the south into the adjacent parking lot. If, over time, parking areas are lost to building expansion, consideration will need to be given to parking structures at that time. The proposed location of the new core hospital is in the area currently occupied by the Mental Health and Family Practice wards. Before starting construction, the occupants of these wards will need to be relocated. The replacement hospital will be developed in two continuous phases. The first phase requires the construction of the Mental Health Building and the new Central Plant/Maintenance Building. The second phase involves the construction of the main hospital and Outpatient/Family Practice Building. The implementation and project schedule is illustrated on page III.110 (Architectural Planning Section). V.2 The project will cost an estimated $95 million to complete assuming continuous construction. The detailed costs are illustrated on page IV.10 (Financial Planning Section). If all project costs are borrowed, the County will need to obtain approximately $124 million in bonds to fund this project. Arthur Young was engaged to determine the feasibility of constructing a replacement hospital for the County. Feasibility was to be evaluated in terms of availability of funding, alternative funding sources and impact on the County's General Fund contribution to the Health Services Department. The availability of funding, as described in Note 11 on page IV.21, has been recently affected by the SB 1732, Medi-Cal capital supplement bill (authored by Senator Robert Presley of Riverside), and the tobacco tax initiative (Proposition 99). SB 1732 (the Presley Bill) permits hospitals contracting to provide Medi-Cal inpatient hospital services and who meet specified criteria to receive reimbursement in addition to their Medi-Cal contract reimbursement for a portion of the costs of capital projects approved by the California Medical Assistance Commission. The projections include Presley funding which is calculated based on 45 percent (assumed Medi-Cal payor mix) of the depreciation, interest and amortization expense for the new hospital. The County has chosen to reflect the income from the Presley fund on the Hospital's financial statements based on the annual depreciation, interest and amortization. This differs from the method in which the proceeds will be distributed. Approximately 45 percent of the revenue gained from the tobacco tax is expected for additional funding for indigent health care services. This is estimated by the Attorney General's Offices to generate $293 million. Proposition 99 revenues have not been included in these projections. Alternative sources of funding are summarized in Note 11 on page IV.21. The following schedule outlines the additional County General Fund contribution to fund the replacement hospital. V.3 ADDITIONAL COUNTY CONTRIBUTION $ 000's 1989 1990 1994 im (1,170) (2,176) (5,586) (1,270) (1,310) All of the above recommendations have met the following objectives identified at the start of the study: • The County provides services for which a demonstrable need exists • The programs capitalize on the County's existing strengths • Maximum use is made of private sector resources • The future health care needs of the elderly poor and medically underserved are met The final objective was that the selected course of action is reasonably affordable. Ultimately, this is a determination that can only be made by the Board of Supervisors. The projections indicate, when compared to the base case, that construction of the replacement hospital can be accomplished without an increase in the County's contribution in 1996, the year after the replacement facility is projected to be completed. The Board of Supervisors should determine if, given the County's mission and current legislative developments, the operating results and construction costs as defined in Exhibits 21-23 meet the criteria of being reasonably affordable. VA APPENDIX A - PATIENT DAY PROJECTIONS f .J �a i �a 3 APPENDIX A TABLE OF CONTENTS Sebedule Population Projections 1.0 Payor Specific Population, Use Rate and Market Share - Base Case 1.1.1 `i Base Case Patient Day Acute vs. Psychiatric Allocation Percentages 1.1.2 Base Case Patient Day Projections 1.1.3 Payor Specific Population, Use Rate and Market Share - Program Alternative 1.2.1 Program Alternative Patient Day Acute vs. Psychiatric Allocation Percentages 1.2.2 Program Alternative Patient Day Projections 1.2.3 I ..s •ppO.. W�O Nf-Pz N.O M P.TW �0a0R _ O. 0 000 It 00.0 OO�O�OM MO.- 0000 W•OP f-M•0 14,%t In SSW MO Opti 1- Q P.t1A.0 NCO O.O.00 �z; aaIp� . O. NNOP �N �M�t NST f� S•O I..TMN MOS 0 0 0 co &1NA 60 t--M 1A N.- co t1 0. 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H 11 S S d U d 0 H a 11 =Y a U 1 0 d 11 S>=d U a 0 H APPENDIX B - BASELINE FINANCIAL PROJECTIONS 3 i --s .r J �1 J 3 1 APPENDIX B TABLE OF CONTENTS Pa�+e s� 1 Patient Days 1 i 2 Rate Increase Statistics 3 Revenues 4 Operating Expenses 5 f Revenue by Financial Class 10 ,Y Hospital Operations Statement of Income & Expenses 27 s d • : NN ►OP Pn NGMS V NP PvPmpPnOOOON O .p MONS p N VM pO • '�"�N MPI ♦'O N ' fV N O� NM N.1�� O M V _ �t^Mi.Ii itP iprp�i ai rl rrk.I�K ri yp� .spy .qp �qy.p p�pp p. 8 M.10� 0O AON•OOVN Ob •P : `NOMNd P .O V MP1�tlNN •O .ONMON� O Nf.f N M NN IV O M . AAAAVy�N.Ia��yyp spp�yy O A.O�AA op p� Q 'OMOP� O 14 P11-4 O •� • AM N.O N.1 P SM'P•11I�NN � „„ pp . p O .I p 1 •'—'N A ♦�O N ' NINfMNN^ O MSI ft P" S M 1 O • �rr�yyrr r. rpr i� W• vm It it0�! 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